The role of common mental and physical disorders in days out of role in the Iraqi general population: Results from the WHO World Mental Health Surveys

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Abstract

In an effort to support mental health policy planning efforts in conjunction with the reconstruction of Iraq, a nationally representative face-to-face household survey was carried out that assessed the prevalence and correlates of common mental disorders in the Iraqi population. A total of 4332 adult (ages 18+) respondents were interviewed (95.2% response rate). The current report presents data on the role impairments (number of days out-of-role in the past 30 days) associated with the nine mental disorders assessed in the survey in comparison to the impairments associated with ten chronic physical disorders also assessed in the survey. These disorders were all assessed with the WHO Composite International Diagnostic Interview. Days out-of-role were assessed with the WHO Disability Assessment Schedule. Both individual-level and societal-level effects of the disorders were estimated. Strongest individual-level predictors were bipolar and drug abuse disorders (176–195 days per year), with mental disorders making up five of the seven strongest predictors. The strongest population-level predictors were headache/migraine and arthritis (22–12% population proportions). Overall population proportions were 57% of days out-of-role due to the chronic physical disorders considered here and 18% for the mental disorders. Despite commonly-occurring mental disorders accounting for more individual-level days out-of-role than the physical disorders, mental disorders are much less likely to receive treatment in Iraq (e.g., due to stigma). These results highlight the need for culturally tailored mental health prevention and treatment programs in Iraq.

Introduction

Iraq has been greatly affected by violence and economic strain over the past 30 years (e.g., Iran–Iraq war in the 1980s; first Gulf War and economic sanctions in the 1990s). More recently, it is estimated that armed violence resulted in nearly 350,000 deaths and injuries between 2003 and 2010 (Hicks et al., 2011) and that the unemployment rate was as high as 28% in 2004 (Trading Economics, 2013). Given the widely recognized associations between violence exposure, unemployment, and adverse mental and physical health outcomes (Boynton-Jarrett et al., 2008, McKee-Ryan et al., 2005, Linn et al., 1985, Murthy, 2007, Murthy and Lakshminarayana, 2006, Shaw and Krause, 2002), researchers have recently started examining the prevalence and correlates of mental and physical disorders in Iraq. In the Iraqi Mental Health Survey, for example, Alhasnawi et al. (2009) found that anxiety disorders were the most common class of disorder and major depression was the most common individual disorder. Younger age was associated with greater risk of having a disorder, and only 2.2% of the sample reported receiving mental health treatment over the prior year. Similar studies of physical disorders have found hypertension and musculoskeletal disorders (e.g., pain) to be particularly common among Iraqis. However, this research has been limited by relying on refugee samples living in neighboring countries rather than nationally representative samples living in Iraq (Doocy et al., 2013, Mateen et al., 2012).

Nonetheless, the extant literature provides important descriptive information that can be used to inform health care decisions in Iraq, an area of reform that has been prioritized during the reconstruction. The general consensus is that Iraq has a need for public health preventative interventions and primary care-based screening and treatment (Al Hilfi et al., 2013, Jaafar and Iraq Ministry of Health, 2008), particularly in the area of mental health (Fleck, 2004, Humphreys and Sadik, 2006). Given the limited resources available, it is important to make decisions about developing and implementing such programs based on information about comparative disease burden and comparative treatment effectiveness (Davis et al., 2005, Loeppke et al., 2009, Special Committee on Health and Productivity Management and National Health Care Financing, 2009, Suhrcke et al., 2012). In addition to defining burden in terms of condition-specific rates or morbidity and mortality (Special Committee on Health and Productivity Management and National Health Care Financing, 2009), recent research has also considered information on the impairments associated with different health problems, such as the effects of these problems on days out of role (Davis et al., 2005, Suhrcke et al., 2012) and role performance (Andlin-Sobocki et al., 2005, Loeppke et al., 2009, Merikangas et al., 2007, Stang et al., 2006, Von Korff, 2009). It is useful to evaluate relative impairments of specific conditions using epidemiological data rather than data collected in treatment samples in order to deal with the fact that severity of disorder is associated with seeking treatment (Ormel et al., 2008) and the possibility that barriers to seeking treatment can vary across conditions.

Although nationally representative samples have been used to estimate disorder impairments in several countries (Alonso et al., 2013, Merikangas et al., 2007, Stang et al., 2006), no study to our knowledge has examined the burden associated with different mental and physical disorders in post-autocratic Iraq. One advantage of the direct assessment of both prevalence and impairment in the same epidemiological survey is that it allows an important problem with the use of health valuations by expert raters to be addressed: that the latter ratings do not take into consideration the fact that health problems are often highly comorbid and the possibility that the burdens of individual conditions vary as a function of comorbidity (Stang et al., 2006, Von Korff, 2009). Accordingly, the purpose of the current report is to inform health care reform in Iraq by estimating the individual- and societal-level burden (i.e., days out of role) of commonly occurring mental disorders and chronic physical conditions.

Section snippets

Sample

The Iraqi Mental Health Survey is a nationally representative epidemiological survey of 4332 adults (18 years +) that was carried out in Iraq in 2006–2007 under the direction of the Iraq Ministry of Health, the Iraq Central Organization for Statistics, and Information Technology (COSIT), the Ministry of Health of the Kurdistan region (MoHK), and the Kurdistan Regional Statistics Office (KRSO) in conjunction with the WHO World Mental Health Surveys (www.hcp.med.harvard.edu/wmh). A stratified

Socio-demographic characteristics

The sample consisted of 4332 respondents with an average age of 36.9 (range of 18–96), with roughly equal numbers of men and women and 65.6% married. Roughly three-quarters (78.2%) of respondents had at least 12 years of education. Whereas 68.2% of men were employed, most women were not (86.9%). The survey did not assess religion given the sensitive nature of the topic at the time of data collection. Although sex-varying employment rates are consistent cultural norms, it is also important to

Discussion

This paper reports from the first large-scale general-population survey in Iraq of the associations of chronic physical and mental disorders with days out of role. As over half of the sample was not employed (e.g., 52.2% females identified themselves as homemakers), the burden estimates provided here reflect days out of role from both paid work duties as well as unpaid activities (e.g., household responsibilities). Both physical and mental disorders were found to be associated with considerable

Contributors

Dr. Al-Hamzawi, the lead investigator in the Iraq Mental Health Survey, was responsible for data collection. Dr. Al-Hamzawi and Dr. Bruffaerts collaborated in writing the first draft of the paper and contributed to the final manuscript after a second draft was written by Dr. Kessler. Dr. Rosellini and Dr. Kessler collaborated in revising the manuscript for resubmission. Ms. Lindberg and Dr. Petukhova were responsible for carrying out data analyses and provided critical comments on the first and

Role of the funding source

The Iraq Mental Health Survey (IMHS) is carried out in conjunction with the World Health Organization World Mental Health (WMH) Survey Initiative which is supported by the National Institute of Mental Health (NIMH; R01 MH070884), the John D. and Catherine T. MacArthur Foundation, the Pfizer Foundation, the US Public Health Service (R13-MH066849, R01-MH069864, and R01 DA016558), the Fogarty International Center (FIRCA R03-TW006481), the Pan American Health Organization, Eli Lilly and Company,

Conflict of interest

Dr. Kessler has been a consultant for AstraZeneca, Analysis Group, Bristol-Myers Squibb, Cerner-Galt Associates, Eli Lilly & Company, GlaxoSmithKline Inc., HealthCore Inc., Health Dialog, Hoffman-LaRoche, Inc., Integrated Benefits Institute, John Snow Inc., Kaiser Permanente, Matria Inc., Mensante, Merck & Co, Inc., Ortho-McNeil Janssen Scientific Affairs, Pfizer Inc., Primary Care Network, Research Triangle Institute, Sanofi-Aventis Groupe, Shire US Inc., SRA International, Inc., Takeda Global

Acknowledgments

We thank the staff of the WMH Data Collection and Data Analysis Coordination Centres for assistance with instrumentation, fieldwork, and consultation on data analysis. A complete list of all within-country and cross-national WMH publications can be found at http://www.hcp.med.harvard.edu/wmh/.

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