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The Demography of Mental Health Among Mature Adults in a Low-Income, High-HIV-Prevalence Context

Abstract

Very few studies have investigated mental health in sub-Saharan Africa (SSA). Using data from Malawi, this article provides a first picture of the demography of depression and anxiety (DA) among mature adults (aged 45 or older) in a low-income country with high HIV prevalence. DA are more frequent among women than men, and individuals affected by one are often affected by the other. DA are associated with adverse outcomes, such as poorer nutrition intake and reduced work efforts. DA also increase substantially with age, and mature adults can expect to spend a substantial fraction of their remaining lifetime—for instance, 52 % for a 55-year-old woman—affected by DA. The positive age gradients of DA are not due to cohort effects, and they are in sharp contrast to the age pattern of mental health that has been shown in high-income contexts, where older individuals often experience lower levels of DA. Although socioeconomic and risk- or uncertainty-related stressors are strongly associated with DA, they do not explain the positive age gradients and gender gap in DA. Stressors related to physical health, however, do. Hence, our analyses suggest that the general decline of physical health with age is the key driver of the rise of DA with age in this low-income SSA context.

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References

  1. Arriaga, E. E. (1984). Measuring and explaining the change in life expectancies. Demography, 21, 83–96.

    Article  Google Scholar 

  2. Baird, S., de Hoop, J., & Özler, B. (2011). Income shocks and adolescent mental health (World Bank Policy Research Working Paper No. 5644). Washington, DC: World Bank. Retrieved from http://ideas.repec.org/p/wbk/wbrwps/5644.html

  3. Bandawe, C. R. (2010). Gap analysis for the National Health Research Agenda of Malawi: Research priorities for the theme of mental health. Lilongwe, Malawi: National Commission for Science and Technology (NCST), Health Research Capacity Strengthening Initiative (HRCSI).

  4. Banejee, A. V., & Duflo, E. (2007). The economic lives of the poor. Journal of Economic Perspectives, 21(1), 141–167.

  5. Blanchflower, D. G., & Oswald, A. J. (2008). Is well-being U-shaped over the life cycle? Social Science & Medicine, 66, 1733–1749.

    Article  Google Scholar 

  6. Bor, J., Herbst, A. J., Newell, M.-L., & Bärnighausen, T. (2013). Increases in adult life expectancy in rural South Africa: Valuing the scale-up of HIV treatment. Science, 339, 961–965.

    Article  Google Scholar 

  7. Canavan, M. E., Sipsma, H. L., Adhvaryu, A., Ofori-Atta, A., Jack, H., Udry, C., . . . Bradley, E. (2013). Psychological distress in Ghana: Associations with employment and lost productivity. International Journal of Mental Health Systems, 7(1), 9. doi:10.1186/1752-4458-7-9

  8. Carey, B. (2016, April 12). Aid groups aim to put mental health on world agenda. New York Times. Retrieved from http://nyti.ms/25YBsJI

  9. Carleton, R. N., Mulvogue, M. K., Thibodeau, M. A., McCabe, R. E., Antony, M. M., & Asmundson, G. J. (2012). Increasingly certain about uncertainty: Intolerance of uncertainty across anxiety and depression. Journal of Anxiety Disorders, 26, 468–479.

    Article  Google Scholar 

  10. Carrieri, V. (2012). Social comparison and subjective well-being: Does the health of others matter? Bulletin of Economic Research, 64, 31–55.

    Article  Google Scholar 

  11. Chisholm, D., Sweeny, K., Sheehan, P., Rasmussen, B., Smit, F., Cuijpers, P., & Saxena, S. (2016). Scaling-up treatment of depression and anxiety: A global return on investment analysis. Lancet Psychiatry, 3, 415–424.

    Article  Google Scholar 

  12. Collins, P. Y., Insel, T. R., Chockalingam, A., Daar, A., & Maddox, Y. T. (2013). Grand challenges in global mental health: Integration in research, policy, and practice. PLoS Medicine, 10(4), e1001434. doi:10.1371/journal.pmed.1001434

    Article  Google Scholar 

  13. Daar, A., Jacobs, M., Wall, S., Groenewald, J., Eaton, J., Patel, V., . . . Ndtei, D. (2014). Declaration on mental health in Africa: Moving to implementation. Global Health Action, 7. doi:10.3402/gha.v7.24589

  14. Dalal, S., Beunza, J. J., Volmink, J., Adebamowo, C., Bajunirwe, F., Njelekela, M., . . . Holmes, M. D. (2011). Non-communicable diseases in sub-Saharan Africa: What we know now. International Journal of Epidemiology, 40, 885–901.

  15. Delavande, A., & Kohler, H.-P. (2009). Subjective expectations in the context of HIV/AIDS in Malawi. Demographic Research, 20(article 31), 817–874. doi:10.4054/DemRes.2009.20.31

    Article  Google Scholar 

  16. Delavande, A., & Kohler, H.-P. (2016). HIV/AIDS-related expectations and risky behavior in Malawi. Review of Economic Studies, 83, 118–164.

    Article  Google Scholar 

  17. Ebrahim, S., Pearce, N., Smeeth, L., Casas, J. P., Jaffar, S., & Piot, P. (2013). Tackling non-communicable diseases in low- and middle-income countries: Is the evidence from high-income countries all we need? PLoS Medicine, 10(1), e1001377. doi:10.1371/journal.pmed.1001377

    Article  Google Scholar 

  18. Floyd, S., Marston, M., Baisley, K., Wringe, A., Herbst, K., Chihana, M., . . . Zaba, B. (2012). The effect of antiretroviral therapy provision on all-cause, AIDS and non-AIDS mortality at the population level—A comparative analysis of data from four settings in Southern and East Africa. Tropical Medicine & International Health, 17(8), e84–e93. doi:10.1111/j.1365-3156.2012.03032.x

  19. Freeman, E. (2012). Older adults’ experiences of ageing, sex and HIV infection in rural Malawi (Doctoral dissertation). Department of Social Policy, of the London School of Economics, London, UK. Retrieved from http://etheses.lse.ac.uk/544/

  20. Freeman, E., & Anglewicz, P. (2012). HIV prevalence and sexual behavior at older ages in rural Malawi. International Journal of STD & AIDS, 23, 490–496.

    Article  Google Scholar 

  21. He, W., Muenchrath, M. N., & Kowal, P. (2012). Shades of gray: A cross-country study of health and well-being of the older populations in SAGE countries, 2007–2010 (International Population Reports P95/12-01). Washington, DC: U.S. Census Bureau. Retrieved from http://www.census.gov/prod/ 2012pubs/p95-12-01.pdf

  22. Jack, H., Stein, A., Newton, C. R., & Hofman, K. J. (2014). Expanding access to mental health care: A missing ingredient. Lancet Global Health, 2, e183–e184. doi:10.1016/S2214-109X(14)70029-4

  23. Jacob, K. S., & Patel, V. (2014). Classification of mental disorders: A global mental health perspective. Lancet, 383, 1433–1435.

    Article  Google Scholar 

  24. Kessler, R. C., & Bromet, E. J. (2013). The epidemiology of depression across cultures. Annual Review of Public Health, 34, 119–138.

    Article  Google Scholar 

  25. Kohler, I. V., Kohler, H.-P., Anglewicz, P., & Behrman, J. R. (2012). Intergenerational transfers in the era of HIV/AIDS: Evidence from rural Malawi. Demographic Research, 27(article 27), 775–834. doi:10.4054/DemRes.2012.27.27

    Article  Google Scholar 

  26. Kohler, H.-P., Watkins, S. C., Behrman, J. R., Anglewicz, P., Kohler, I. V., Thornton, L., . . . Kalilani-Phiri, L. (2015). Cohort profile: The Malawi Longitudinal Study of Families and Health (MLSFH). International Journal of Epidemiology, 44, 394–404.

  27. Kroenke, K., & Spitzer, R. L. (2010). Instruction manual: Instructions for patient health questionnaire (PHQ) and GAD-7 measures. Retrieved from http://www.phqscreeners.com/instructions/instructions.pdf

  28. Lancet. (2011). Mental health care: The economic imperative. Lancet, 378, 1440.

  29. Loeb, M., & Jonas, B. S. (2015). Psychological and physical functioning difficulties associated with complex activity limitations among U.S. adults. Disability and Health Journal, 8, 70–79.

    Article  Google Scholar 

  30. López-Ulloa, B. F., Møller, V., & Sousa-Poza, A. (2013). How does subjective well-being evolve with age? A literature review. Journal of Population Ageing, 6, 227–246.

    Article  Google Scholar 

  31. Lund, C. (2010). Mental health in Africa: Findings from the Mental Health and Poverty Project. International Review of Psychiatry, 22, 547–549.

    Article  Google Scholar 

  32. Lund, C. (2014). Poverty and mental health: Towards a research agenda for low and middle-income countries. Commentary on Tampubolon and Hanandita (2014). Social Science & Medicine, 111, 134–136.

    Article  Google Scholar 

  33. Lund, C., Breen, A., Flisher, A. J., Kakuma, R., Corrigall, J., Joska, J. A., . . . Patel, V. (2010). Poverty and common mental disorders in low and middle income countries: A systematic review. Social Science & Medicine, 71, 517–528.

  34. Macran, S., Weatherly, H., & Kind, P. (2003). Measuring population health: A comparison of three generic health status measures. Medical Care, 41, 218–231.

    Google Scholar 

  35. Malawi National Statistical Office. (2010). Welfare Monitoring Survey (WMS) 2009. Zomba: National Statistical Office of Malawi. Retrieved from http://www.nsomalawi.mw/publications/welfare-monitoring-surveys-wms/welfare-monitoring-surveys-wms-2009.html

  36. Mayston, R., Kinyanda, E., Chishinga, N., Prince, M., & Patel, V. (2012). Mental disorder and the outcome of HIV/AIDS in low-income and middle-income countries: A systematic review. AIDS, 26, S117–S135.

    Article  Google Scholar 

  37. McKinnon, B., Harper, S., & Moore, S. (2013). The relationship of living arrangements and depressive symptoms among older adults in sub-Saharan Africa. BMC Public Health, 13(1), 682. doi:10.1186/1471-2458-13-682

    Article  Google Scholar 

  38. Msyamboza, K. P., Ngwira, B., Dzowela, T., Mvula, C., Kathyola, D., Harries, A. D., & Bowie, C. (2011). The burden of selected chronic non-communicable diseases and their risk factors in Malawi: Nationwide STEPS survey. PloS One, 6(5), e20316. doi:10.1371/journal.pone.0020316

    Article  Google Scholar 

  39. Murray, C. J. L., Vos, T., Lozano, R., Naghavi, M., Flaxman, A. D., Michaud, C., . . . Lopez, A. D. (2012). Disability-adjusted life years (DALYS) for 291 diseases and injuries in 21 regions, 1990–2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet, 380, 2197–2223.

  40. Nation. (2012, August 11). Malawi grappling with mental health problems. Nation. Retrieved from http://mwnation.com/malawi-grappling-with-mental-health-problems/

  41. Niles, A. N., Sherbourne, C. D., Roy-Byrne, P. P., Stein, M. B., Sullivan, G., Bystritsky, A., & Craske, M. G. (2013). Anxiety treatment improves physical functioning with oblique scoring of the SF-12 short form health survey. General Hospital Psychiatry, 35, 291–296.

    Article  Google Scholar 

  42. Ntsekhe, M., & Damasceno, A. (2013). Recent advances in the epidemiology, outcome, and prevention of myocardial infarction and stroke in sub-Saharan Africa. Heart, 99, 1230–1235.

    Article  Google Scholar 

  43. Nybo, H., Gaist, D., Jeune, B., McGue, M., Vaupel, J. W., & Christensen, K. (2001). Functional status and self-rated health in 2,262 nonagenarians: The Danish 1905 Cohort Survey. Journal of the American Geriatrics Society, 49, 601–609.

    Article  Google Scholar 

  44. Patel, V., Garrison, P., de Jesus Mari, J., Minas, H., Prince, M., & Saxena, S. (2008). The Lancet’s series on Global Mental Health: 1 year on. Lancet, 372, 1354–1357.

    Article  Google Scholar 

  45. Payne, C. F., & Kohler, H.-P. (2017). The population-level impact of public-sector antiretroviral therapy rollout on adult mortality in rural Malawi. Demographic Research, 36(article 37), 1081–1108. doi:10.4054/DemRes.2017.36.37

    Article  Google Scholar 

  46. Payne, C. F., Mkandawire, J., & Kohler, H.-P. (2013). Disability transitions and health expectancies among adults 45 years and older mature in Malawi: A cohort modeling approach. PLoS Medicine, 10(5), e1001435. doi:10.1371/journal.pmed.1001435

    Article  Google Scholar 

  47. PHQ. (2011). Patient Health Questionnaire (PHQ) screeners: Screener overview. Retrieved from http://www.phqscreeners.com/overview.aspx

  48. Prince, M., Patel, V., Saxena, S., Maj, M., Maselko, J., Phillips, M. R., & Rahman, A. (2007). No health without mental health. Lancet, 370, 859–877.

    Article  Google Scholar 

  49. Rantanen, T., Harris, T., Leveille, S., Visser, M., Foley, D., Masaki, K., & Guralnik, J. M. (2000). Muscle strength and body mass index as long-term predictors of mortality in initially healthy men. Journal of Gerontology, Series A: Biological Sciences and Medical Sciences, 55, M168–M178.

    Article  Google Scholar 

  50. Reijer, D. B. J. (2013). Grandparents as parents: Skipped-generation households coping with poverty and HIV in rural Zambia (Doctoral dissertation). Social and Behavioural Sciences, Amsterdam Institute for Social Science Research (AISSR), Amsterdam, The Netherlands. Retrieved from http://hdl.handle.net/11245/1.398404

  51. Salomon, J. A., Wang, H., Freeman, M. K., Vos, T., Flaxman, A. D., Lopez, A. D., & Murray, C. J. L. (2012). Healthy life expectancy for 187 countries, 1990–2010: A systematic analysis for the Global Burden Disease Study 2010. Lancet, 380, 2144–2162.

    Article  Google Scholar 

  52. Sareen, J., Jacobi, F., Cox, B. J., Belik, S. L., Clara, I., & Stein, M. B. (2006). Disability and poor quality of life associated with comorbid anxiety disorders and physical conditions. Archives of Internal Medicine, 166, 2109–2116.

    Article  Google Scholar 

  53. Sorsdahl, K., Slopen, N., Siefert, K., Seedat, S., Stein, D. J., & Williams, D. R. (2011). Household food insufficiency and mental health in South Africa. Journal of Epidemiology and Community Health, 65, 426–431.

    Article  Google Scholar 

  54. Steptoe, A., Deaton, A., & Stone, A. A. (2015). Subjective wellbeing, health, and ageing. Lancet, 385, 640–648.

    Article  Google Scholar 

  55. Stieglitz, J., Schniter, E., von Rueden, C., Kaplan, H., & Gurven, M. (2015). Functional disability and social conflict increase risk of depression in older adulthood among Bolivian forager-farmers. Journals of Gerontology, Series B: Psychological Sciences and Social Sciences, 70, 948–956.

    Article  Google Scholar 

  56. Stone, A. A., Schwartz, J. E., Broderick, J. E., & Deaton, A. (2010). A snapshot of the age distribution of psychological well-being in the United States. Proceedings of the National Academy of Sciences, 107, 9985–9990.

    Article  Google Scholar 

  57. Susser, E., & Patel, V. (2014). Psychiatric epidemiology and global mental health: Joining forces. International Journal of Epidemiology, 43, 287–293.

    Article  Google Scholar 

  58. Sweetland, A. C., Belkin, G. S., & Verdeli, H. (2014). Measuring depression and anxiety in Sub-Saharan Africa. Depression and Anxiety, 31, 223–232.

    Article  Google Scholar 

  59. Thapa, S. B., Martinez, P., & Clausen, T. (2014). Depression and its correlates in South Africa and Ghana among people aged 50 and above: Findings from the WHO Study on Global AGEing and Adult Health. Journal of Psychiatry,17(6). doi:10.4172/1994-8220.1000167

  60. United Nations Development Programme (UNDP). (2010). 2010 Malawi millennium development goals report. New York, NY, and Lilongwe, Malawi: UNDP and Malawi Ministry of Development Planning and Cooperation.

  61. United Nations Development Programme (UNDP). (2014). Human development report 2014—Sustaining human progress: Reducing vulnerabilities and building resilience. New York, NY: UNDP.

    Google Scholar 

  62. United Nations Population Division. (2012). World Population Prospects, the 2012 revision: Standard (median) forecasts. New York, NY: United Nations, Department of Economic and Social Affairs, Population Division. Retrieved from http://esa.un.org/unpd/wpp/

    Google Scholar 

  63. Ware, J. E., Kosinksi, M., & Keller, S. D. (1998). SF-12: How to score the SF12 Physical and Mental Health Summary Scales (3rd ed.). Lincoln, RI: QualityMetric.

    Google Scholar 

  64. World Health Organization (WHO). (2010). World malaria report 2010. Geneva, Switzerland: World Health Organization. Retrieved from http://www.who.int/malaria/world_malaria_report_2010/en/

  65. World Health Organization (WHO). (2013). Mental health action plan 2013–2020. Geneva, Switzerland: WHO. Retrieved from http://www.who.int/mental_health/publications/action_plan/en/

  66. Yang, Y. (2007). Is old age depressing? Growth trajectories and cohort variations in late-life depression. Journal of Health and Social Behavior, 48, 16–32.

    Article  Google Scholar 

  67. Yang, Y., & Land, K. C. (2013). Age-period-cohort analysis: New models, methods, and empirical applications. Boca Raton, FL: CRC Press.

    Book  Google Scholar 

  68. Yang, Y., & Lee, L. C. (2010). Dynamics and heterogeneity in the process of human frailty and aging: Evidence from the U.S. older adult population. Journals of Gerontology, Series B: Psychological Sciences and Social Sciences, 65, 246–255.

    Article  Google Scholar 

  69. Zimmer, Z., & Das, S. (2014). The poorest of the poor: Composition and wealth of older person households in sub-Saharan Africa. Research on Aging, 36, 271–296.

    Article  Google Scholar 

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Acknowledgments

We gratefully acknowledge the generous support for the Malawi Longitudinal Study of Families and Health (MLSFH) by the Rockefeller Foundation; the National Institute of Child Health and Human Development (NICHD, Grant Nos. R03 HD05 8976, R21 HD050653, R01 HD044228, R01 HD053781); the National Institute on Aging (NIA, Grant Nos. P30 AG12836 and R21 AG053763); the Boettner Center for Pensions and Retirement Security at the University of Pennsylvania; and the NICHD Population Research Infrastructure Program (Grant Nos. R24 HD-044964), all at the University of Pennsylvania. We are also grateful for support through the Swiss Programme for Research on Global Issues for Development (SNF r4d Grant 400640_160374) as well as pilot funding received through the Penn Center for AIDS Research (CFAR), supported by NIAID AI 045008 and the Penn Institute on Aging. Collin Payne also gratefully acknowledges support through a United States National Science Foundation Graduate Research Fellowship (Grant No. DGE-0822).

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Correspondence to Iliana V. Kohler or Hans-Peter Kohler.

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Kohler, I.V., Payne, C.F., Bandawe, C. et al. The Demography of Mental Health Among Mature Adults in a Low-Income, High-HIV-Prevalence Context. Demography 54, 1529–1558 (2017). https://doi.org/10.1007/s13524-017-0596-9

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Keywords

  • Aging
  • Malawi
  • Mental health
  • Depression
  • Anxiety