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Correspondence |
The Royal London Hospital (St Clement's), 2a Bow Road, London E3 4LL
I read with interest Mumford et al's (2000) paper on stress and psychiatric disorder in urban Rawalpindi. Their findings and explanations of a lower prevalence of common mental disorders in an urban area compared with a rural area of Pakistan (Mumford et al, 1997) need to be treated with caution.
Their study population is unrepresentative of the city as a whole. Although they studied an urban slum, strictly speaking, it is a relatively ‘prosperous’ urban slum. The assets and income of this population lie between the fourth and the richest quintile for the Pakistani population (Gwatkin et al, 2000). The use of only male interviewers for female subjects in an orthodox society is also a source of potential bias and cannot be ignored. This was not the case in the rural study. Thus, their findings are unlikely to be generalisable to the urban population of Rawalpindi or other cities of Pakistan. A more plausible explanation for their findings is that financial prosperity together with strong and varied social networks might be associated with a lower prevalence of common mental disorders. Their study attempts to address one aspect of urbanisation due to rural migration, rather than looking at stress and psychiatric disorder in urban Rawalpindi.
REFERENCES
Gwatkin, D., Rustein, S., Johnson, S., et al (2000) Socioeconomic Differences in Health, Nutrition and Population in Pakistan. Washington, DC: HNP/Poverty Thematic Group, The World Bank.
Mumford, D. B., Saeed, K., Ahmad, I., et al
(1997) Stress and psychiatric disorder in rural Punjab. A
community survey. British Journal of Psychiatry,
170,
473-478.
Mumford, D. B., Minhas, F. A., Akhtar, I., et al
(2000) Stress and psychiatric disorder in urban Rawalpindi.
Community survey. British Journal of Psychiatry,
177,
557-562.
Division of Psychiatry, University of Bristol, 41 St Michael's Hill, Bristol BS2 8DZ
It is difficult to find a truly representative area of any city, since its districts vary greatly in socio-economic terms. Nevertheless, we made a careful selection in Rawalpindi of a recently established housing area, with poor public utilities, of middle to lower socio-economic status. As presented in our paper, the socio-economic findings confirmed our choice and revealed a wide social spectrum. For example, among men, 31% had had no formal education yet 38% had been educated to tertiary college level. Over half the house-holds had an income of less than 5000 rupees (currently worth £55) per month.
As it happens, the socio-economic status of the nearby rural population in our Gujar Khan study (Mumford et al, 1997) was quite similar to that in Rawalpindi in terms of education and income, and in fact they reported greater ownership of most electrical appliances. So financial prosperity alone is not a plausible explanation for the very striking difference we found in psychiatric morbidity (i.e. less than half) in urban Rawalpindi compared with a rural village in the Punjab.
Whether urban populations in Pakistan indeed have more "strong and varied social networks" than rural populations, as Dr Mirza suggests, remains to be investigated, but this is doubtful. We are planning further studies to determine to what extent the quality of life in the city, as opposed to selective migration, can account for the enormous rural—urban differences in psychiatric morbidity. Replication of our study in other cities in Pakistan would be very useful.
However, the truly remarkable finding is not the prevalence of common mental disorders in urban Rawalpindi, which is more in line with rates reported elsewhere in the world. It is the exceptionally high rate of psychiatric morbidity in rural villages in Pakistan, recently confirmed by other investigators in another village near Gujar Khan (Hussain et al, 2000); this cries out for further research.
Regarding the use of male doctors to conduct the second-stage interviews of female subjects, we were obliged to do the same in the previous study in rural Chitral (Mumford et al, 1996). However we have found no psychometric inconsistencies between the three epidemiological surveys (in Chitral, Gujar Khan and Rawalpindi) to suggest that this was a source of bias while making psychiatric diagnoses according to ICD—10 criteria for research.
REFERENCES
Hussain, N., Creed, F. & Tomenson, B. (2000) Depression and social stress in Pakistan. Psychological Medicine, 30, 395-402.[CrossRef][Medline]
Mumford, D. B., Nazir, M., Jilani, F. M. et al
(1996) Stress and psychiatric disorder in the Hindu Kush. A
community survey of mountain villages in Chitral, Pakistan. British
Journal of Psychiatry, 168,
299-307.
Mumford, D. B., Saeed, K., Ahmad, I., et al (1997) Stress and psychiatric disorder in rural Punjab. A community survey. British Journal of Psychiatry, 170, 473-478.
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