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London School of Hygiene and Tropical Medicine, UK, and Sangath, Porvorim, Goa, India
London School of Hygiene and Tropical Medicine, UK
Sangath, Porvorim, Goa, India
London School of Hygiene and Tropical Medicine, UK
Correspondence: Dr Vikram Patel, Sangath, 831/1 Alto-Porvorim, Goa, India 403521. Fax: +91 832 2411709; email: Vikram.patel{at}lshtm.ac.uk
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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Method Population-based cohort study of 2494 women aged 18 to 50 years, in India. The Revised Clinical Interview Schedule was used for the detection of common mental disorders.
Results There were 39 incidentcases of common mental disorder in 2166 participants eligible for analysis (12-month rate 1.8%, 95% CI 1.3–2.4%). The following baseline factors were independently associated with the risk for common mental disorder: poverty (low income and having difficulty making ends meet); being married as compared with being single; use of tobacco; experiencing abnormal vaginal discharge; reporting a chronic physical illness; and having higher psychological symptom scores at baseline.
Conclusions Programmes to reduce the burden of common mental disorder in women should target poorer women, women with chronic physical illness and who have gynaecological symptoms, and women who use tobacco.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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METHOD |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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Sample
The study population comprised women aged 18–45 years living in nine
villages of the catchment area of the Aldona Primary Health Centre
(n=8595); 3000 women were randomly selected from the population
registers maintained by the health department. The eligibility criteria for
recruitment were age between 18 and 50 years (since the enumeration registers
were up to 4 years old in some villages); residence in the area for the next
12 months; speaking one of the study languages (Konkani, English, Hindi,
Marathi); and not being currently pregnant. If a randomly selected woman did
not meet all these criteria, then the researcher was instructed to replace her
using a priori criteria for identifying an eligible woman
(Patel et al,
2006).
Recruitment and follow-up
Recruitment took place over a 19-month period from November 2001 to May
2003. Details of the recruitment procedure and data collection have been
described in earlier publications (Patel
et al, 2006). In brief, the mandatory requirements for
participation were a face-to-face interview with a trained researcher, and the
collection of vaginal or urine specimens for the diagnosis of reproductive
tract infection. Participants who consented to a gynaecological examination
also had their blood pressure, weight and height measured. All recruits who
consented to participate and completed the recruitment procedures were
reviewed at 6 and 12 months after recruitment. Thus, there were three rounds
of data collection: at recruitment, and at 6 and 12 months (reviews).
Risk factors
Risk factors were assessed at recruitment. We conducted a semi-structured
interview, which was a composite of items derived from existing interviews
used in other studies of reproductive and mental health in Goa. The interview
was evaluated in a pilot study; interrater reliability of key variables was
moderate to high (kappas from 0.58 to 0.87). The data collected from these
sources were organised in the following manner for the analyses of risk
factors.
Socio-economic risk factors
Information on the participant’s age, education, religion and marital
status was collected. Economic status was measured by means of questions on
type of housing, access to water and a toilet, household income, employment
status, indebtedness and the experience of hunger due to lack of money to buy
food in the previous 3 months.
Psychological factors
Two measures were used for psychological health. The Scale for Somatic
Symptoms measures symptoms that are features of somatoform disorders. The
scale elicits the experience of 20 common somatic symptoms in the previous 2
weeks (Chaturvedi & Sarmukaddam,
1987), in four categories: pain-related symptoms such as headache
and body ache; sensory symptoms such as hot or cold sensations and tingling;
nonspecific symptoms such as tiredness and weakness; and symptoms of
biological dysfunction such as poor sleep and constipation. Each symptom is
rated on a Likert scale (0–2) of increasing severity. The scores of
these four scales were summed to generate a somatoform disorder symptom score
for each participant. The second measure was the Revised Clinical Interview
Schedule (CIS–R), a structured interview for the measurement and
diagnosis of common mental disorder in community and primary care settings
(Lewis et al, 1992).
The CIS–R is the instrument for the UK national surveys of psychiatric
morbidity, and has been widely used in developing countries, including India.
The Konkani language version of the CIS–R administered in the present
study had been previously followed in Goa
(Patel et al, 1998).
The interview consists of 14 sections, each covering specific symptoms such as
anxiety, depression, irritability, fatigue, obsessions, compulsions and panic.
The sum of the section scores generates a total score, a measure of
non-psychotic psychiatric morbidity. Scores >11 signify case-level
morbidity. In addition, interview data can be processed using the PROQSY
software to generate ICD–10 diagnostic categories
(World Health Organization,
1992).
Reproductive health factors
Participants were asked about pregnancies; numbers of pregnancies and their
outcome were recorded, with more detailed history of pregnancy in the previous
12 months. Participants who were sexually active were asked about their
experience of difficulty in conception in the previous 12 months. A menstrual
history elicited the experience of irregular menstrual cycles and
dysmenorrhoea in the previous 12 months. Participants were asked about their
experience of five gynaecological symptoms (abnormal vaginal discharge,
dysuria, lower abdominal pain, genital itching and dyspareunia) in the
previous 3 months. Definitions of these symptom categories were derived from
guidelines for reproductive health research
(Jejeebhoy et al,
2003).
Gender disadvantage factors
Questions covered five domains. The first domain was elicited as part of
the socioeconomic factors, i.e. marital history; being widowed or divorced
poses specific disadvantages for women in South Asia. In addition, being
married or having had a pregnancy during adolescence (<20 years old)
indicate restricted productive choices. The second domain covered the lifetime
experience of verbal, physical and sexual violence by the spouse and concerns
about the spouse’s substance use habits. Violence experienced from any
other person was elicited from all participants. The third domain covered the
autonomy the woman had to make decisions regarding visiting her mother’s
or friend’s home, seeing a doctor, keeping money aside for personal use,
and having time to do things for herself; the responses to these four items
(each scored 0–2) were combined to generate an autonomy score (range
0–8). The fourth domain enquired about the level of engagement, in the
past 3 months, with four activities: religious activities, participation in a
community or voluntary group, social outings to meet friends or relatives, and
having friends or relatives visit her. The responses to these four items (each
scored 0–4) were combined to generate a social integration score (range
0–16). The fifth domain consisted of items regarding support from family
when faced with five different situations (good news, a personal problem,
needing to borrow a small amount of money, feeling low and when ill). The
responses to these five items (each scored 0–1) were combined to
generate a family support score (range 0–5).
Physical health factors
Estimation of haemoglobin was based on a finger-prick sample of blood,
using the Hemocue system (Krenzischeck
& Tanseco, 1996). Anaemia was evaluated as a categorical
variable (absent, Hb
11 g/dl; mild to moderate, Hb 8–10.9 g/dl;
severe, Hb<8g/g/8 dl). The medical examination data collected from
participants who consented to see the gynaecologist included weight, height
and blood pressure. Body mass index (BMI) values were categorised (<17;
17–19; 20–24; and >25 kg/m2). Items of the WHO
Disability Assessment Schedule (DAS;
Chwastiak & Von Korff,
2003) that measure physical disabilities (standing for long
periods, household responsibilities, walking a long distance, getting dressed,
washing whole body, day-to-day work) were added to generate a physical
disability score (range 6–17). The diagnosis of reproductive tract
infection was established using gold-standard laboratory tests: polymerase
chain reaction assay for chlamydial and gonococcal infections, culture for
trichomonas vaginalis and Gram-stained slides for candidiasis and
bacterial vaginosis (Meehan et
al, 2003). The presence of other chronic health problems was
based on self-report of the presence of a long-standing illness; participants
were asked about the nature of the illness.
Outcome measures
The CIS–R data were processed using the PROQSY software to generate
ICD–10 diagnoses. The primary outcome was the presence of an
ICD–10 diagnosis equivalent to a common mental disorder, i.e. any
anxiety or depressive disorder, at either of the reviews.
Analysis
Analyses of the risk factors of common mental disorders were carried out
for participants who completed at least one review and who did not have a
common mental disorder at recruitment. Logistic regression was used for all
analyses, with incident case of common disorder as the outcome. First,
univariate analyses were performed for each socio-economic risk factor; all
those with P
0.1 were included in a multivariate model. The
factors with P0.1 in this multivariate model were retained for
subsequent analyses. Next, the associations of risk factors in the other
domains (gender disadvantage, mental health and reproductive and physical
health) with common mental disorder were estimated. The factors with
P<0.1 in univariate analyses were adjusted for the socio-economic
factors identified above; those for which P remained below 0.1,
together with the socio-economic factors, formed the final multivariate model.
Analysis of obstetric risk factors and factors associated with spousal
relationships were restricted to married participants. In the final model,
which included all the women, variables with missing values had the values
recoded as 9. For categorical variables with evidence of linearity, a
P-value for trend is shown; otherwise the P-value shows the
overall significance of the variable. Continuous variables such as age,
household income, autonomy score, social integration score, family support
score, physical disability, somatoform disorders score, CIS–R score,
household size and income were converted to categorical variables (e.g.
tertiles or quartiles) based on the distribution of scores. Reproductive tract
infections were treated as a composite variable of any reproductive tract
infection or any sexually transmitted infection (chlamydia, gonorrhoea,
trichomoniasis). All significance tests are two-tailed.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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At least one review was completed by 2317 women, 151 of whom had a common mental disorder at recruitment; the analyses presented are thus based on the sample of 2166 women who completed at least one review and did not have a common mental disorder at recruitment. The study flow chart is shown in Fig. 1. A total of 39 participants had an incident common mental disorder; 31 were diagnosed as having mixed anxiety–depressive disorder and 8 as having depressive disorder. Thus the overall 12-month rate of new episodes of common mental disorder was 1.8% (95% CI 1.3–2.4%).
Socio-economic risk factors
The baseline socio-economic factors most strongly associated with the risk
for common mental disorders were related to deprivation and poverty, i.e. low
level of education, low household income, lack of access to running water in
the home, having experienced hunger and difficulties in making ends meet
(Table 1). Compared with single
women, married and divorced/widowed women were at significantly elevated risk.
When these baseline factors were combined in a multivariate model, the
following remained significantly associated with common mental disorders:
being married (OR=6.52, 95% CI 1.6–27.3); being divorced or widowed
(OR=6.04, 95% CI 0.8–44.3); higher total monthly household income
(OR=0.37, 95% CI 0.1–1.1 for the highest quartile compared with the
lowest); and the experience of difficulties in making ends meet (OR=2.82, 95%
CI=1.4–5.6).
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Psychosocial risk factors
Baseline factors indicative of gender disadvantage, i.e. younger age at
marriage, concern about the husband’s substance misuse habits, and
violence from others (typically in-laws for married women and parents for
single women), were found to be strongly associated with common mental
disorders in univariate analyses, but not after adjustment for socio-economic
factors. Three types of marital abuse were elicited; none was associated with
common mental disorders in univariate analyses; a composite variable of any
marital abuse was also not associated with common mental disorders (OR=1.82,
95% CI 0.8–4.0). Baseline sub-case threshold psychological morbidity and
symptoms of somatoform disorders at recruitment were associated with increased
risk of common mental disorders, as were tobacco and alcohol use in the
previous 3 months; these associations remained significant after adjustment
for socio-economic factors (Table
2).
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Reproductive and physical health risk factors
Having had a pregnancy, younger age at first pregnancy and having had
multiple pregnancies were all associated with common mental disorders in
univariate analyses, but were not significant after adjustment for
socio-economic factors. Gynaecological complaints (vaginal discharge, lower
abdominal pain, dysuria and irregular menstrual periods) were associated with
an increased risk and these associations remained evident after adjustment for
socio-economic factors; 294 participants reported a long-standing illness or
disability and 287 of them described the nature of this illness. The most
common illnesses were cardiovascular diseases (101), diabetes (25) and spinal
or back disorders (25). These, and physical disability at baseline, were
significantly associated with common mental disorders after adjustments.
However, none of the baseline biological markers of poor physical health
(anaemia, reproductive or sexually transmitted infections, hypertension or low
or high BMI) was associated with increased risk, either in univariate analyses
or after adjustment (Table
3).
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Final model
In the final multivariate model (Table
4), the following baseline factors were significantly associated
with the onset of common mental disorders: abnormal vaginal discharge, low
household income, having difficulty making ends meet, being married, divorced
or widowed, smoking cigarettes or chewing tobacco in the previous 3 months,
suffering from a chronic illness and sub-threshold psychological
morbidity.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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In view of the strong associations reported in cross-sectional surveys between domestic violence and common mental disorders (Kumar et al, 2005; Patel et al, 2006), we were surprised that this was not an independent risk factor after adjustment for poverty and marital status in our longitudinal analysis. Several reasons may explain this; the rates of exposure to domestic violence were lower in our sample than those reported for women in India (Jejeebhoy, 1998); and the association between domestic violence and poor mental health in surveys may be partly explained by recall bias, reverse causality or confounding by socio-economic deprivation. However, we did find a strong, and independent, association between being widowed, divorced or married and an increased risk for common mental disorder. We think that the most likely explanation for the association with being widowed or divorced is related to social isolation and stigma; and we suggest that the increased risk in married women is at least partly due to their having to cope with multiple roles and leading potentially more restricted lives in their marital homes.
Gynaecological morbidity and common mental disorders
Recent cross-sectional surveys have shown that psychological factors,
including common mental disorders, are major risk factors
(Prasad et al, 2003;
Patel et al, 2005)
for abnormal vaginal discharge, one of the most common health complaints in
women in South Asia. Gynaecological complaints are often culturally determined
somatic idioms of distress for women facing severe social disadvantage and
psychological distress (Patel &
Oomman, 1999). Ethnographic studies in South Asia have reported
that women typically attribute their gynaecological symptoms to tension in
their lives and to symptoms of tiredness and weakness, which in turn are often
associated with heavy physical work and social disadvantage
(Bang & Bang, 1994). Our
study suggests that one mechanism for the association reported in
cross-sectional analyses is that such symptoms, which may have a variety of
aetiologies, lie along the pathway between long-term social and interpersonal
difficulties and common mental disorder. The lack of association between
biological indicators of reproductive health and common mental disorders
suggests that the social contexts of gynaecological symptoms, including their
possible impact on marital relationships, are the most plausible proximal
mechanisms of association.
Other risk factors
Our study replicated the association of three well-defined risk factors for
common mental disorder: sub-threshold psychological morbidity, tobacco use and
chronic illness. A recent review confirms the high levels of comorbidity of
physical and mental health problems and that this association is bidirectional
(Evans et al, 2005).
Several mechanisms may explain this association, including common biological
pathways for some chronic diseases and common mental disorder, the adverse
effects of treatments for chronic diseases and the impact of pain and
disability associated with chronic diseases on mental health. The latter is
the most likely pathway; the association between physical disability and
common mental disorders was markedly attenuated after adjustment for chronic
physical illness. Substance use, of both alcohol and tobacco, was associated
with common mental disorder, and the association with tobacco use (smoked or
chewed) remained significant after adjustment for socio-economic and other
risk factors. This finding replicates similar reports from longitudinal
studies in developed countries which have reported these associations
(Wagena et al, 2005).
Several mechanisms might be considered to explain this association, but the
fact that the association has been reported for the first time in a
non-Western setting where tobacco use among women is relatively rare (1.7%)
and where most tobacco is chewed, points to the role of biological factors
related to neuropharmacological effects of nicotine on neurotransmitter
systems linked to depression (Breslau
et al, 1998). Other plausible mechanisms can also be
considered, for example confounding by unmeasured life difficulties which
predict both tobacco use and common mental disorder. Unsurprisingly, in our
study current psychological symptoms were associated with the risk of common
mental disorders, which may be partly an artefact resulting from the
dichotomisation into case and non-case categories of scores measuring the
symptoms of depression and anxiety, which are typically continuously
distributed in populations.
Limitations and implications
We did not measure biological indicators for chronic illnesses. However, we
were able to measure indicators for locally relevant exposures reflecting
nutrition and reproductive health. The overall participation rate in the study
was high and the attrition rate was relatively low, enhancing our confidence
in the generalisability of the findings. However, there might have been a
selection bias at recruitment such that women with physical health problems
were more likely to participate. In using a categorical approach based on a
diagnostic algorithm to define our outcome, we will have missed an unknown
number of women with clinically significant symptoms of common mental disorder
which did not meet ICD–10 case criteria, i.e. sub-threshold morbidity
which may be associated with adverse impact and help-seeking
(Demyttenaere et al,
2004).
The implications of our findings are that public health and clinical interventions aimed at reducing the burden of common mental disorders in women must target those who are poor and facing acute economic problems. It is plausible that community development activities which enhance women’s education and attenuate the impact of poverty will promote mental health. Advocacy is needed by global and national health-policy makers to highlight the greater vulnerability of the poor to common mental disorder and strengthen the capacity of health services to address these disorders. Screening may help identify women with common mental disorders, particularly in clinical settings such as gynaecological or medical clinics, where women with gynaecological symptoms and chronic illnesses seek help. However, such screening programmes must be twinned with effective management strategies for common mental disorders. Reproductive and primary healthcare must incorporate a strong emphasis on the assessment of the mental health and social circumstances of women with gynaecological symptoms or chronic illnesses. The threshold for interventions for common mental disorders may need revision; women with sub-threshold symptoms, at the very least, need closer follow-up to improve early detection and management. Women who are using tobacco are also a high-risk group; interventions for early detection and treatment of common mental disorders should target women tobacco users. Further research is needed to identify the mechanisms through which some of the associations we have found are mediated; for example, what is the mechanism for the association between tobacco use and common mental disorders? Similarly, longitudinal studies examining the access and barriers to effective and affordable care for common mental disorders among poorer communities in low- and middle-income countries are needed; coping strategies which promote recovery and resilience may help identify mechanisms which promote mental health even in the context of economic adversity.
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ACKNOWLEDGMENTS |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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This study was funded by a Wellcome Trust Career Development Fellowship in Clinical Tropical Medicine, to V.P.
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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Breslau, N., Peterson, E. L., Schultz, L. R., et al
(1998) Major depression and stages of smoking. A longitudinal
investigation. Archives of General Psychiatry,
55, 161
–166.
Breslau, N., Schultz, L. R., Johnson, E. O., et al
(2005) Smoking and the risk of suicidal behavior: a
prospective study of a community sample. Archives of General
Psychiatry, 62, 328
–334.
Chaturvedi, S. & Sarmukaddam, S. (1987) Somatizers in psychiatric care. Indian Journal of Psychiatry, 29, 337 –342.
Chwastiak, L. A. & Von Korff, M. (2003) Disability in depression and back pain: evaluation of the World Health Organization Disability Assessment Schedule (WHO DAS II) in a primary care setting. Journal of Clinical Epidemiology, 56, 507 –514.[CrossRef][Medline]
Demyttenaere, K., Bruffaerts, R., Posada-Villa, J., et
al (2004) Prevalence, severity, and unmet need for
treatment of mental disorders in the World Health Organization World Mental
Health Surveys, JAMA,
291, 2581
–2590.
Evans, D. L., Charney, D. S., Lewis L., et al (2005) Mood disorders in the medically ill: scientific review and recommendations. Biological Psychiatry, 58, 175 –189.[CrossRef][Medline]
Goldberg, D. & Huxley, P. (1992) Common Mental Disorders: A Biosocial Model. London: Tavistock/Routledge.
International Institute for Population Sciences (2001) National Family Health Survey–2, 1998–99: India. Mumbai: IIPS.
Jejeebhoy, S. (1998) Wife-beating in rural India: a husband’s right? Evidence from survey data. Economic and Political Weekly, 11 April, 855 –862.
Jejeebhoy, S., Koenig, M. & Elias, C. (2003) Reproductive Tract Infections and Other Gynaecological Disorders: A Multi-disciplinary Research Approach. Cambridge: Cambridge University Press.
Krenzischeck, D. & Tanseco, F. (1996) Comparative study of bedside and laboratory measurements of haemoglobin. American Journal of Critical Care, 5, 427 –432.[Abstract]
Kumar, S., Jeyaseelan, L., Suresh, S., et al
(2005) Domestic violence and its mental health correlates in
Indian women. British Journal of Psychiatry,
187, 62
–67.
Lewis, G., Pelosi, A., Araya, R., et al (1992) Measuring psychiatric disorders in the community: a standardized assessment for use by lay interviewers. Psychological Medicine, 22, 465 –486.[Medline]
Meehan, M., Wawer, M. J., Serwadda, D., et al (2003) Laboratory methods for the diagnosis of reproductive tract infections and selected conditions in population-based studies. In Reproductive Tract Infections and Other Gynaecological Disorders: A Multidisciplinary Approach (eds S. Jejeebhoy, M. Koenig & C. Elias), pp. 261–282. Cambridge: Cambridge University Press.
Patel, V., Pereira, J. & Mann, A. (1998) Somatic and psychological models of common mental disorders in India. Psychological Medicine, 28, 135 –143.[CrossRef][Medline]
Patel, V. & Oomman, N. M. (1999) Mental health matters too: gynecological morbidity and depression in South Asia. Reproductive Health Matters, 7, 30 –38.
Patel, V. & Kleinman, A. (2003) Poverty and common mental disorders in developing countries. Bulletin of the World Health Organization, 81, 609 –615.[Medline]
Patel, V., Pednekar, S., Weiss, H., et al
(2005) Why do women complain of vaginal discharge? A
population survey of infectious and psychosocial risk factors in a South Asian
community. International Journal of Epidemiology,
34, 853
–862.
Patel, V., Kirkwood, B. R., Pednekar, S., et al
(2006) Gender disadvantage and reproductive health risk
factors for common mental disorder in women: a community survey in India.
Archives of General Psychiatry,
63, 404
–413.
Piccinelli, M. & Wilkinson, G. (2000)
Gender differences in depression. Critical review. British Journal
of Psychiatry, 177, 486
–492.
Prasad, J., Abraham, S., Akila, B., et al (2003) Symptoms related to the reproductive tract and mental health among women in rural Southern India. National Medical Journal of India, 16, 303 –308.[Medline]
Wagena, E. J., van Amelsvoort, L. G., Kant, I., et al
(2005) Chronic bronchitis, cigarette smoking, and the
subsequent onset of depression and anxiety: results from a prospective
population-based cohort study. Psychosomatic Medicine,
67, 656
–660.
World Health Organization (1992) International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD–10). Geneva: WHO.
World Health Organization (2001) The World Health Report 2001. Mental Health: New Understanding, New Hope.Geneva: WHO.
Received for publication January 28, 2006. Revision received June 21, 2006. Accepted for publication August 1, 2006.
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
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