Acta psychiatr. scand. 1985:71:417-426 Key words: Psychiatric morbidity; outpatients; transcultoral psychiatry; general hospital psychiatry; Ethiopia.

Psychiatric morbidity and psychosocial n an outpatient population of background i a general hospital in western Ethiopia
L. Jacobsson

Department of Psychiatry, University of UmeA, Sweden

ABSTRACT - The psychiatric morbidity in 465 outpatients seen at a general hospital in western Ethiopia was found to be 18 %. The great majority of cases had neurotic conditions often with a somatic shading, only six were psychotic. A few were themselves aware that they were suffering from mental disorders. There was no tendency for the mental disorders to be correlated to somatic disorders. The psychiatric morbidity rate seemed increased in women, in younger patients and in patients with higher educational level and income.
Received July 25,1984; accepted f o r publication September 24, 1984

It is apparent that mental disturbances do not receive proper recognition in the medical system of clinics and hospitals operating in developing countries. For example, cases of mental disturbances are seldom mentioned in reports to the Public Health Department from rural clinics in the Wollega province of western Ethiopia. There are also very few, if any, psychiatric cases in reports on the diagnostic panorama from various general hospitals in Ethiopia. Giel et al. (l), however, found a psychiatric morbidity of 18 % in 200 medical outpatients in one of the general hospitals in Addis Abeba. Dormar et al. (2) found a psychiatric morbidity of 16.2 % in a Police Hospital and 6.8 % i na rural general hospital outpatient clientele, and Giel & van Luijk (3) found a psychiatric morbidity of 19 % in a health center clientele in a small rural Ethiopian town. In order to contribute to the epidemiology
2 7 '

o f mental disorders in Ethiopia, and to provide evidence of the psychiatric work done in a general hospital, a survey was made of the outpatient population of a general hospital in western Ethiopia. The data could also contribute to the discussion on how to improve psychiatric service in this context, as the general hospital will continue to be the major psychiatric facility in developing countries for many years to come. The town and the hospital have been described elsewhere (4).

Methods
The investigation was carried out over two periods of two weeks each: 2-15 November 1962, Ethiopian calendar (July 1970: European calendar) and 26 April- 7 May 1962, Ethiopian calendar (January 1971: European

418 L. JACOBSSON
calendar). The first period was in the middle of the rainy season and the second during the dry season. During the first period all patients aged 15 years or more who attended because of a new complaint were examined, 229 in all. These patients were also given Hb, ESR and stool tests. During the second period the number of patients increased to more than double, thus only every second patient was sent to the author for investigation, 236 in all. Their socio-economic background was recorded on a special form by one of the nurses. The author then made a detailed examination with regard to earlier and present mental disturbances. A careful somatic examination was also made using the hospital's excellent laboratory and X-ray facilities to get as close a diagnosis as possible. At the time of the first investigation period the author had had almost 1 year's experience of working at the hospital. Unfortunately, most communication with the patients took place through interpreters. These, however, were well-trained and experienced and co-operation with both them and the nurses was very good. The patients were classified according to the bodily system to which the complaint was related and according to Kessel's classification of psychiatric morbidity (5). Only the main complaint or disorder which the author considered to be the major one was registered, although one patient often had several different complaints and disorders. Almost 75 % of the patients, for example, had intestinal parasites which often they did not consider worth treating. The disorders were registered according to the organ involved, for example, malaria was registered under diseases of the blood, pneumonia under respiratory system, headache under nervous system, etc. Special note was made of infectious diseases as they are of a particular interest in developing countries. The psychiatric morbidity according to Kessel has been used earlier in the same kind of investigations in Ethiopia by Giel and coworkers (1-3, 6). The patients are classified in four groups according to the following criteria:

I.

Patients complaining of explicit psychological problems such as being nervous, depressed, having feelings of anxiety, etc. 11. Patients complaining of somatic symptoms not adequately explained after physical examination and laboratory tests as somatic disorders, for example, burning sensations in the body, abdominal feelings of cramp and discomfort, shortness of breath, dizziness, etc. 1 1 1 . Patients with indisputable somatic disorders but in one way or another abnormal psychic reactions to these. IV. Personality disorders with no direct relation to the current disease. This original model was modified so that Group I also included patients whose complaints the author considered mainly mental, but who were themselves unaware of the relation between somatic and mental disturbances. Patients belonging to these four groups (I-IV) are here defined as displaying Psychiatric Morbidity.

Socio-economic background
188 of the 465 patients were from Nakamte town and most of the others lived within 50 km of Nakamte.

Fig. I. Wollega province.

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419

Table 1 Age and sex distribution and psychiatric morbidity (PM) Males Age range
~~

PM %
22.9 11.0 6.4 15.8

Females PM %
~~~~~~

Total
N
~

PM %
24.7 14.3 7.1 18.3

15-29 30-49 50

118 82 47 247

109 86 23 218

26.6 17.4 8.7 21.1

227 168 70 465

Total

Table 2 Ethnic group and psychiatric morbidity (PM) Males Tribe Galla Amhara Others: Tigrae, Gurage, Arab Total
N
191 37 19 247

PM 70
15.2 16.2 21.1 15.8

Females PM %
16.8 33.3 36.4 21.1

Total
N
353 82 30 465

PM %
15.9 25.6 26.7 18.3

162 45

11
218

Table 3 Religion and psychiatric morbidity (PM)

~ ~~ ~ ~~~~~

Males Religion Christian: Coptic Orthodox Evangelic Roman Catholic Muslim Animists, others Total
N
203 26 1 13 4 247

PM %
13.3 38.5

Females N PM %
178 15 25 20.2 26.7

Total
N

PM %
16.5 34.1 18.4 25.0 18.3

15.4 25.0 15.8

20.0

381 41 1 38 4 465

218

21.1

Age and sex distribution is shown in Table 1. These data are only approximate because most people only knew their age to within 5 years. Relatively more men than women attended the clinic. The ratio of medwomen at OPD was 1:13 compared with that in Wollega province 0:92 (7). The age group 15-29 years was overrepresented in relation t o the total population of Wollega. The ethnic distribution is shown in Table 2. The Gallas make up the majority while the Amharas are a rather large minority consisting of people who have moved in from other parts of

Ethiopia. These people are mainly officials. The Tigraes are usually well-educated people in government service working as teachers, etc. The Gurages and the Arabs are usually traders. Most of the patients stated that they were Coptic Christians (Table 3). Evangelical Christians made up a relatively small group considering that there is a rather large Evangelical church in the town and that the hospital was run by the Evangelical mission. There were few animists as, among other things, the traditional Galla religion has a low status compared t o the Coptic confession, which

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L. JACOBSSON

Table 4 Civil status and psychiatric morbidity (PM) Males Status Single Married Divorced Widowed Total
N
78 161 6 2 247

PM %
21.8 12.4 100.0 15.8

Females PM %
48.3 15.5 36.4 20.0 21.1

Total
N

PM %
30.0 14.0 23.5 33.3 18.3

29 168 11 10 218

107 329 17 12 465

Table 5 Education and psychiatric morbidity (PM) Education

N

Males PM %
6.2 10.9 43.4 11.8 15.8
N

Females PM %
17.4 37.5 36.4 40.0 21.1

Total
N

PM %
13.1 18.2 42.2 18.2 18.3

None Elementary school grade 1-6 Sec. school - high school grade 7-12 Religous school Arab school Total

113 64 53 17 247

178 24 1 1 5 218

291 88 64 22 465

Table 6 Profession and psychiatric morbidity (PM) Psychiatric morbidity Total Farmers, cultivators Housewives Students Teachers, higher officials and technicians Lesser office employees, police, drivers, etc. Daily workers, servants, bar girls, tedj-sellers, etc. Total
183 90 31 29 67 65 465
%

8.7 27.8 35.5 31.0 7.5 29.2 18.3

dominates. Many reported that they belonged to the Coptic church whilst in practice they were still animists. Civil status is shown in Table 4 . According to official statistics (7) 55 % of the total population is single, 30 % married, 4.1 % widowed and only 1.5 % divorced. (The number of single persons is slightly higher than the number of people under 20 years of age). The frequency of divorce is high and it is not un-

common for a person to have been married two or three times. In a survey of a rural village near Nakamte (8) 31 % of all those who had ever been married had also been divorced one or more times. The level of education is shown in Table 5. More than 60 % were illiterate, which is a low figure compared with the figures for the province as a whole where 94 % of the population over 10 years of age is illiterate. As well

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421

Table 7 Categories of disorders and psychiatric morbidity Diagnosis Mental, psychoneurotic personality disorders Blood and lymphatic system Nervous system Eyes Ears Circulatory system Respiratory system 8. Gastro-intestinal system 9. Genito-urinary system 10. Skin and cellular tissue 11. Bones and organs of movement 12. Endocrine systsm 13. Ill-defined 14. General infections: typhoid, smallpox, etc. 15. Fighting cases 16. Accidents 17. Transferral cases
1. 2. 3. 4. 5. 6. 7.

Total No. of patients

24 26 16 13 9 6 56 123
85

Infectious disorders
25

Psychiatric morbidity
24 -

36 20 4 15 8
8 9 7

2 6 6 46 41 35 24 2 8

1 3 36 6 2

5 5

3
5

192

Total

465

85

as government and mission schools are the

schools belonging to the Coptic Church where the priests and depteras give some education that consists mainly of memorizing texts from the Bible and holy scripts, usually in Ghees, the old church language which is often not understood even by the priests. The pupils might learn to read some Amharic but there is usually no instruction in writing. Professional status is shown in Table 6. Farmers make up the single dominant group but there is a large group of students and middle-class people, policemen and various office workers. Among the women there is a rather large group of bar girls who are often also prostitutes.

General morbidity
(Modified International Classification) Table 7 shows the different categories of disorders. A majority of patients suffered from respiratory, gastro-intestinal and genito-urinary diseases and many of these are due to infectious agents. The majority of patients with genito-urinary tract disorders are women.

During the rainy season there are more cases of malaria, typhus and other infectious diseases. One case of smallpox was admitted during the dry season. 42 % of all cases were due to infectious agents. Anaemia is prevalent in spite of the high iron-intake. Anaemia limits recommended by WHO adjusted for altitude, viz., 13.9 g% for males and 12.8 g% for females (9), revealed that 57 % of the males and 64 % of the females had Hb values below the limit. 36 % of the total number of patients had an ESR above 20 mm and 50 % had an ESR below 10 mm. Intestinal parasites were examined by direct microscopy. Only 27 % had negative stool tests. 14 % of the patients were admitted to the hospital, only six patients with psychiatric morbidity (PM) were admitted. There was no difference in the admission rate between the two seasonal groups. Two of the patients died, one of a perforated ulcer and one of heart failure.

Psychiatric morbidity
The figures for Psychiatric morbidity are given in Table 7. The majority of psychiatric

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L. JACOBSSON

Table 8 Categories of psychiatric morbidity Category of psychiatric morbidity

1. Explicitly psychological-clear psychiatric cases 2. Unexplained physical symptoms 3. Abnormal reaction to physical illness

Male
13 22
4

Female
5 35
4

Total
18 57 8 2
85

4. Personality disorders
~~ ~

39

2
46

Total

cases, apart from the group of mental diseases, was found in the group of gastrointestinal disturbances where 28 % displayed Psychiatric morbidity. The categories of psychiatric morbidity according to Kessel (5) are shown in Table 8.
Group I : Explicitly Psychological comprised those who explicitly complained of being anxious, irritable, etc. or were recognized by the author as clear psychiatric cases. Only eight of the patients realized themselves that they were suffering from more or less explicitly psychic disturbances; four were psychotic, two complained of impotence, one student recognized his problem as mainly psychological and one man was exhausted after one day of intense mourning following his mothers death. In total, six were psychotic on admission; one had attempted suicide during a depressive, confusional state caused by a typhus infection, one had a recidivating psychosis with hallucinations, one had a confusional postpartum psychosis, one a recidivating depressive psychosis and one an unspecific psychosis - confused, attempted to run away, etc. One prisoner was admitted in a psychotic state of hysterical reaction. The other patients in category I were psychoneurotic cases with symptoms of tension and anxiety; palpitations, nausea, sweating, shortness of breath, dizziness, sleep disturbances, epigastric burning, pain all over, headache, irritable etc. Group 11: Unexplained Somatic Symptoms comprised psychoneurotic patients with mainly hypochondriacal reactions: pain and burning in the epigastric region, headache, burn-

ing and moving sensations here and there, pains and feelings of coldness, and a wide variety of symptoms not adequately explained by the findings or from laboratory tests. There were also additional symptoms and signs of tension and anxiety, or records from earlier visits of diffuse complaints or certified psychiatric findings.
Group III: Abnormal Reaction to Physical Illness consisted of people who over-reacted to very insignificant disorders. For example, two male students who acted as if their jaws were about to explode when their last molars were erupting. This must be seen against the otherwise stoic tolerance of pain and disaster shown by most of the patients. Group IV: Personality Disorders comprised two women, one was mentally defective with hysterical symptoms, and attended the clinic frequently, the other displayed an aggressive, restless, impulsive personality. Table 9 gives a classification of the disorders according t o the WHO-diagnostic manual (ICD 8, 1965). The great majority of cases can be referred to neurotic disturbances, often with a somatic shading. The patients who displayed psychiatric morbidity were less often anaemic than the others and there were also fewer cases with a high ESR in this group. There was no difference as regards a positive stool test.

Psychiatric morbidity and socioeconomic background

There was a tendency for women to display

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423

Table 9 Diagnosis of psychiatric disorders according to WHO classification

294.20 294.40 296.99 300.00 300.10 300.40 300.70 300.99 301.99 305.50 307.99 790.20 791.99

Psychosis c morbo infectionis Psychosis in puerperio Psychosis affectiva NUD Neurosis angoris incl. reactio angoris Neurosis hysterica incl. reactio hysterica Neurosis depressiva Neurosis hypochondrica incl. reactio hypochondrica Neurosis NUD Persona pathologica Gastritis Causal mental disturbance Depressio mentis NUD Cephalagia Total

1
1 1

24 8 2 12 9 2 13 6 1 5

85

PM more than men and the highest frequency is found in the age range 15-29 years in both sexes (Table 1). People belonging to ethnic groups other than the Gallas, tended to display a higher frequency of PM (Table 2). Evangelic Christians displayed a higher frequency of psychiatric morbidity than Coptic Christians and Muslims (Table 3). Married people had the lowest frequency of PM, single and divorced women the highest (Table 4). 20 % of the people married by mutual agreement displayed PM compared with 11 % in the group married through elders. The PM rate increases with educational level. 42 % of those with a higher education, secondary school and high school, displayed PM (Table 5). Farmers and lesser office employees, policemen, drivers, etc. had the lowest frequency of PM, while students, housewives and people with a higher educational level had the highest (Table 6 ) . Within the group of farmers, tenants displayed a higher frequency of PM (12 %) than landowners (7 %).

Discussion
As regards statistica1 analysis the author has refrained from testing the statistical significance of the differences because of the nature of the data, which in his view should be treated more as evidential rather than representative.

The general finding of psychiatric morbidity in 18.3 % of an out-patient population of a general hospital in rural Ethiopia is in close agreement with the findings of Giel and coworkers mentioned earlier. The great majority of cases had neurotic conditions, but there were also some psychotic patients. In a study of the clientele of a Swedish general practitioner using the same method (10) psychiatric morbidity occurred in 35 % of his cases. Only 9.2 % of these patients recognized, however, that their problems were mainly due to mental disturbance. In contrast to the findings of Giel et al. (3) there was a tendency for more women than men to display psychiatric morbidity. This, however, is in line with the findings of, e.g., Shepherd et al. (11) in a London general practice and von Knorrings cited above. Also as opposed to Giel et al. (3, 12) there was a tendency for married people to display a lower frequency of psychiatric morbidity than those who were single or divorced. People married in the traditional way through elders are better off than those married the less traditional way. The finding that the psychiatric morbidity rate increases with educational level and income agrees with the findings of Giel et al. (12) in a rural hospital population, but is not supported by their findings in other out-patient populations (1, 3). There are two main explanations for the relationship between socio-

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L. JACOBSSON

economic background factors and psychiatric morbidity. One is that there is a difference in illness behaviour between different social groups. The more educated and economically better off are more inclined to turn to modern medicine for help when disturbed, whilst the tradition-oriented groups tend to rely on healers of various kinds. This could also explain the higher frequency of psychiatric morbidity among younger people from ethnic groups other than the original inhabitants, viz. Amharas, Tigrae, etc. who usually are more educated and less traditional in their thinking. The higher frequency among Evangelic Christians who are usually somewhat less traditional than the Coptics and the Muslims might also be thus explained. Another possible interpretation of these differences is that there might be different rates of psychiatric morbidity in different social groups due to the varying degree of stress they are under. The higher frequency of PM among educated, other ethnic groups as compared with the traditional Gallas, among younger people, Evangelic Christians, single and divorced women, and among tenants compared with landowners, might well be seen as an effect o f the higher degree of alienation and frustration they experience in a still very traditional society. On the other hand, there are indications that mental illnesses of a psychoneurotic or psychosomatic nature are equally common, irrespective of the degree of urbanization (3, 6). These questions need to be investigated further in epidemiological surveys involving far more subjects than those undertaken so far. It is apparent, however, that a great proportion of patients with psychiatric disorders do attend the general hospitals in developing countries. This proportion will possibly increase due either to a changed illness behaviour or to the higher degree of frustration experienced in a modern society - probably both. Thus, it is necessary to start planning for more adequate care of this category of patients along the lines that have been discussed in detail by, e.g., Giel & Harding (13) and Swift (14).

Appendix

Reports o f some typical

psychiatric cases
Psychosis NUD. 31-year-old married man with tropical ulcer for many years. Four years ago not right in mind, talking nonsense, hallucinating, trying to run away into the forest, and so on. Now somewhat better but is hearing voices again, complaining of insomnia, headache, dizziness. Depressive syndrome. 38-year-old man, married, farmer 2nd carpenter, old tbc-pulm., now heafed. Has had the same symptoms before, periodically. Now complaining of pain in all extremities, difficulty in sleeping, stays in bed in the morning, cannot get up and work as usual, feels depressed and sad, apathetic, dizzy, feeling of faintness, shortness of breath. Organic psychosis - attempted suicide. 30-yearold married man with four children but as afflicted by poverty has had to send some of the children to relatives. Has been sad and easily upset for a long time. Now acutely confused, ran away and tried to hang himself in a tree, but his wife was able to cut him down at once. On admission was found to have a typhus infection with Weil-Felix pos 1:640, fever, hallucinating. Hysterical reaction in a prisoner. 3 1-year-old married man, farmer from Nakamte area, imprisoned. Suddenly ill: falling down, breathing deeply, not speaking. On admission, not talking, closed eyes but not unconscious, no fever. No physical signs of disease. Treated with injections of chlorpromazine, and vitamins and bedrest. Quite well the day after admission, talking, walking, etc. The actual conflict was not revealed. Anxiety-tension in a foreign teacher. 37-yearold male Indian teacher with his family in India. Has attended the clinic previously because of difficulty with breathing, feeling of swelling in his throat. Now abdominal dis-

PSYCHIATRIC MORBIDITY IN WESTERN ETHIOPIA

425

comfort, epigastric pain worsened after food, etc.

Hysteric-epileptical fits. 23-year-old married women with symptoms for 4 months, chest pain, shortness of breath, epigastric pain and occasional vomiting, insomnia, headache. Also some kind of fits, unconscious for 1-3 h, no real cramps, no passing of urine or stool, about two attacks a month. Anamnestically, most probably hysterical symptoms but epilepsy cannot be excluded. Psychoneurosis. 27-year-old woman, married for 12 years, no children, the only wife of her husband. Troubles for many years with headache, back pain, epigastric burning, occasional diarrhoea, pain and itching all over her body, not sleeping well. N o physical findings of relevance. Psychoneurosis. 22-year-old woman, married for about 7 years, no children, shifting pains in the lower abdomen for months and dyspareuni, somewhat depressed, irregular menstruations. Has attended several timcs before because of vague complaints of the same kind without any physical correlates. Anxiety-tension i n a student. 19-year-old boy, 11th grade student complaining of pain in the legs, shoulders and neck. Feeling of weakness in the mornings, but sleeping well, dizziness, eye tiredness, more troubles when studying. Transferral case - impotense and tension in a teacher. Male aged 26 years, teacher, Muslim, married. Feelings o f coldness in the knees, reaching up to the scrotum and penis which is shortened, occasional impotence. Most worried about his impotence. His wife has had difficult deliveries and had a stillbirth 4 months ago which resulted in a vesicovaginal fistula. He has had numerous injections at the local pharmacy, which give tempory relief, but he is soon worse again. Now wants transferral from Mendi, where he lives, to a place with a hospital for his wife. Impotence. Male, 15 years old, not married,

farmers boy from the Gimbi area. Had sexual contact for about 1 year with a married woman in the village, but was afraid of her husband. He also got gonorrheoea and was treated for this 3 months ago, still some pain in right testis. Impotent for the last 4 months.
Unwanted unrecognized pregnancy. 18-yearold girl living with her uncle after her father died and her mother married again. Complaining of no menstruation for 1 year and now distended abdomen, occasional vomiting. The investigation revealed a pregnancy in the 8th month. She denied in spite of careful questioning that she had had any contact with a man or any knowledge of being pregnant.

Post script
The publication of these data collected in 1971 and 1972 has been delayed for many reasons. Perhaps the most important has been the wish to extend the study. As this has become impossible I have decided to publish the data, although fully aware of the studys limitations. I think the information will be of some interest, both now and in the future, as a document on the situation as it was and a basis for comparisons with the situation as it develops.

References
1. Giel R, Gezahegn Y,van Luijk J N . Psychiatric morbidity in 200 Ethiopian medical outpatients. Psychiatr Neurol Neurochir 1968:71:169-176. 2. Dormar M, Giel R, van Iuijk J N. Psychiatric illness in two contrasting Ethiopian outpatient populations. SOCPsychiatry 1974:9:155--161. 3. Giel R, van Luijk J N . Psychiatric morbidity in a small Ethiopian town. Br J Psychiatry 1969:IZ5:149162. 4. Jacobsson L. Mental disorders in patients admitted to a general hospital in western Ethiopia 1960-1970. Acta Psychiatr Scand 1985:71:410-416. 5. Kessel W I N. Psychiatric morbidity in a London general practice. Br J Prevent SOCMed 1960:14:1&22. 6. Giel R, van Luijk J N . Psychiatric morbidity in a rural village in Ethiopia. Int J SOC Psychiatry 1969/ 1970:16:63-71. 7. Imperial Ethiopian Government Central Statistical Office. Report on a survey of Wollega province. Addis Abeba, June 1967. 8. Hermansson S. Girma Nigussie: Survey of Getema vil-

426 L. JACOBSSON
lage, population, housing and living conditions. Wollega Public Health Department, Nakamte, Ethiopia: Stencil, 1967. Hofvander Y. Hematological investigations in Ethiopia with special reference to a high iron intake. Acta Med Scand 1968:Suppl. 494:l-74. von Knorring L. Psykisk sjuklighet bland patienter pi% en provinsiallakarmottagning. Lakartidningen 1973:70: 2171-2173. Shepherd M, Cooper B, Brown A C, Kalton G W. Psychiatric illness in general practice. London: Oxford University Press, 1966. Giel R, Kitaw Y, Workneh F, Mesjin R. Ticket to heaven: Psychiatric illness in a religious community in Ethiopia. SOC Sci Med 1974:8:549-556. 13. Giel R, Harding T W. Psychiatric priorities in developing countries. Br J Psychiatry 1976:128:513-522. 14. Swift C R. Mental health programming in a developing country: any relevance elsewhere? Afr J Psychiatry 1976:2:79-86.

9.

10.

Address
Lars Jacobsson Dept. of Psychiatry University of UmeA S-901 85 Umea Sweden

11.

12.