Journal of Public Health | Vol. 30, No. 4, pp. 487 –493 | doi:10.1093/pubmed/fdn025 | Advance Access Publication 8 April 2008
Prevalence and predictors of mental disorders among women
in Sanliurfa, Southeastern Turkey
Zeynep Simsek1, Dilek Ak1, Abdurrrahman Altindag2, Mehmet Günes2
1
Harran University Faculty of Medicine, Department of Public Health, 63100 Sanliurfa, Turkey
Harran University Faculty of Medicine, Department of Psychiatry, 63100 Sanliurfa, Turkey
Address correspondence to Zeynep Simsek, E-mail: zsimsek@harran edu.tr
2
A B S T R AC T
Background Mental health is one of the most important public health issues because of major contributor to the global burden of disease. In
this study, we examined the prevalence and predictors of mental disorders among married women from 15 to 49 years of age and the need for
mental health services in the primary health care settings.
Methods In this cross-sectional study, 270 women were selected using probability cluster sampling method at 95% confidence interval (91.5%
response rate). The Structured Clinical Interview for DSM-IV (SCID-I) and women socio-demographic information form were used to collect data.
Results Although the prevalence of mental disorder was 25.9% (8.5% with one diagnosis; 17.4% were two or more diagnoses), 4.7% of these
women had contacted a carer in the last year for psychological reasons. According to the SCID-I assessment, the most prevalent diagnoses were
major depressive disorder (7.3%), phobic disorder (4.8%) and posttraumatic stress disorder (3.6%). In this study, comorbid diagnoses were
present in 67.2% of patients. Logistic regression analyses revealed that domestic violence, history of previous trauma, anemia and cutaneous
leishmaniasis were significant predictors of any mental disorders (P , 0.05).
Conclusions These findings highlight the need for systematic development of community-based mental health services in conjunction with
primary health care services for the screening, early identification and treatment of women suffering from mental disorders, and the improvement
of anemia and cutaneous leishmaniasis control programme.
Keywords women, mental disorders, comorbidity, community mental health services
Introduction
Mental disorders are widely recognized as a major contributor (14%) to the global burden of disease worldwide.1,2
According to recent World Health Organization estimates,
nearly 25% of individuals develop one or more mental or
behavioral disorders at some stage in their life, in both
developed and developing countries and one-third of all
years lived with disability worldwide can be attributed to
neuropsychiatric conditions.3 Not only is the prevalence of
mental disorders high but the fact that most conditions go
untreated, are often chronic in course and thus interfere
with the ability of the affected individual to lead a productive and satisfying life, means that mental disorders are
associated with extremely high rates of ill-health and disability.4 Research highlights the importance of individual behavioral factors and physical, material, economic and
psychological factors, and their complex reciprocal relationship, in determining mental health and mental disorders.5
In light of the universal acknowledgement of gender,
women are more likely than men to be adversely affected by
mental disorders, the most common being anxiety and
depression disorders.6 – 11 By 2020, depression is predicted
to be the major burden of disease for women.12 When rates
of major depression at each site were standardized to the
Epidemiologic Catchment Area five site household sample
for the age group 18 – 64, and the result of The Turkish
Mental Health Survey conducted a national representative
sample, the female to male sex ratio ranged between 1.6 and
2.6.13,11 Data from the World Bank study revealed that
depressive disorders accounted for close to 30% of the
Zeynep Simsek, Research Associate
Dilek Ak, Master Degree Student
Abdurrrahman Altindag, Research Associate
Mehmet Günes, Research Assistance
# The Author 2008, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved.
487
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disability from neuropsychiatric disorders amongst women
in developing countries but only 12.6% of that among
men.11
Since gender is a measure of both biological/genetic and
social differences, it is likely that the health inequalities
between men and women discussed earlier reflect both sexrelated biological and social factors, and the interplay
between them.7,14 In terms of social factors, researchers
pose two general hypotheses to account for gender-based
inequalities in health. The differential exposure hypothesis
suggests that women report higher levels of health problems
because of their reduced access to the material and social
conditions of life that foster health,6,15 and from the grater
stress associated with their gender and marital roles. The
differential vulnerability hypothesis, on the other hand,
suggests that women report higher levels of health problems
because they react differently than men to the material,
behavioral and psychosocial conditions that foster health.16
As mentioned above, as women in many countries are
approximately twice as likely as men to experience
depression and it is the most prevalent psychiatric disorder,
any significant reduction in the overrepresentation of
women who are depressed would make an important contribution to lessening the global burden of disease. Therefore,
women’s mental health is a significant public health issue.
Since the need for the effective promotion of good mental
health for women and reduction of mental disorders,
evidence-based research based on risk and protective factors
should be done in every culture and community.
The aims of this study were: (i) to describe the prevalence
of mental disorders in women in a Primary Healthcare
Center Area in Sanliurfa, (ii) to examine the relationship
between background risk factors and mental disorders and
(iii) to determine the mental health needs of women in our
community.
Methods
This cross-sectional study surveyed persons enrolled at the
catchment area of a community-based Primary Healthcare
Center in Sanliurfa of Turkey in 2006. This Healthcare
Center serves 1 05 000 persons of all ages, and 15% of
were female aged 15 –49 years. We calculated to reach 270
women at 95% confidence level, using the probability
cluster sampling method (every cluster included average ten
houses). Cluster selection was done from household records
kept and updated every year by the Healthcare Center. It
contained a list of dwelling units with their whole addresses
(quarter, area, avenue, street, building and door number). A
sampling list was created from these records. Random
selection was employed at every stage. A household was
defined as a person or a group of persons living together
and sharing a common source of food. The sample consisted of 247 women (91.5% of those were eligible) from 15
to 49 years of age and nonpregnant women living in the
catchment area. Of the 270 women in the sample, 11
refused to participate for various reasons and 12 were
pregnant.
Two bilingual (Turkish and Kurdish) research assistants
(trained mental health professionals) did all home visits.
Interviewers introduced themselves, read a standardized set
of paragraphs explaining the study and informed potential
participants that all information was anonymous. Study participants provided verbal informed consent for their participation. After the study period all patients diagnosed with
any mental disorders were directed to Harran University
Faculty of Medicine Department of Psychiatry for their
treatment and follow-up. The first part of the survey consisted of questions pertaining to sociodemographic and clinical variables, the next sections included The Turkish version
of the Structured Clinical Interview for Axes I of the
DSM-IV (SCID-I).17
Independent Variables
Social determinants of health were categorized here into
three broad groups; social structural, behavioral and psychosocial. Social structure was measured by age, size of household, family type, education and economic condition.
Multiple indicators were also used to measure physical
health and health related behaviors such as body mass
index (BMI), anemia, history of cutaneous leishmaniasis
and smoking. The BMI was calculated by dividing weight
in kilograms by height in meters squared, those with a
BMI score of ,18.5 are categorized as having insufficient
weight, 18.6 –24.9 acceptable weight, 25 –29.9 some
excess weight and .30 overweight. Anemia was defined
according to the World Health Organization criterion
(Hb ,12.0 g/dl).18
We asked about trauma experiences (i.e. accident, losses,
economic difficulties) in the 12 months prior to the interview, domestic violence such as physical, verbal and economic, participation in decision-making at home and social
support were defined as psychosocial determinants.
In the end, age, first marriage age, size of household and
number of living children are treated as continuous variables
in the analyses. All other independent variables are treated
as categorical data, and therefore entered in the analysis as
sets of dummy variables.
WO M EN ’S M EN TA L H EALT H
Data Analysis
Data were analysed using the SPSS statistical package.
Bivariate analyses were used to begin to examine relationships between risk factors and mental health status. The
statistical differences between percentages were examined
with the chi-square test, and differences between mean
scores were assessed by a t-test. Predictive factors were
included in the subsequent models if they were significantly
associated at the P , 0.05 level with any outcome variable
in the bivariate analysis. Logistic regression model of
outcome were estimated to determine independent associations of these risk factors with the mental disorders and
for controlling confounders. Statistical significance is defined
as a P-value of 0.05 or lower; logistic regression models
present 95% confidence intervals.
Results
Characteristics of sample
The mean age of participants was 33.3 + 9.4 years, and participants ranged in age from 15 to 49 years and mean first
marriage age of them was 17.9 + 3.1. The average number
of household members was 5.8 + 2.4 and the mean of total
living children was 3.4 + 2.5. Most (74.5%) participants
reported that Kurdish or Arabic were the primary language
spoken at home. The majority (68%) of the sample was illiterate and 16.2% of them had completed only primary
school education. Only 1.6% was employed, others were
housewives; 22.3% of participants reported that they had a
bad economic condition.
Previous trauma events experienced by 36% of the
women including traffic accidents, loss of a family member,
illness and trouble with children or a family member. Two in
three (60.3%) women aged 15– 49 years reported at least
one type of domestic violence, at least once, in their lifetime.
The lifetime prevalence for specific types of violence in our
sample for each category: 30% of women were physically
abused, 29.1% experienced verbal violence at least one time
and about one of three women (27.9%) experienced economic violence.
Prevalence of mental disorders by SCID-I
In the sample, 64 (25.9%) patients met the established
SCID-I criteria for any mental disorders. Of patients, 8.5%
of them were diagnosed only one mental disorder and
17.4% were diagnosed two or more mental disorders. The
most common mental disorder was major depressive disorder (7.3%). The prevalence of phobic disorders, posttraumatic stress disorder, obsessive-compulsive disorder, anxiety
489
due to general medical condition, dysthymic disorder and
panic disorder were 4.8, 3.6, 3.2, 2.2, 1.6 and 1.2%, respectively. In this study, comorbid diagnoses were present in
67.2% of the patients.
Bivariate analyses
Table 1 presents the mean scores of independent variables
including the age of women and husbands, age at first marriage, first motherhood age, number of living children and
number of household members according to the mental
health situation. The factors of husband’s education,
number of living children and size of the household showed
significant relation with the mental disorders (P , 0.05). No
significant relationship was found between mental disorder
and the independent variables listed (P . 0.05) (as shown in
Table 1; age of women/husband, first marriage age, motherhood age and women education).
As shown in Table 2, the frequency of any mental disorder was significantly different according to the history of
previous trauma, anemia, history of leishmaniasis, domestic
violence including physical, verbal and economic, economic
situation and participate to the decision at home (P , 0.05).
There were no significant differences according to the family
type, ethnicity, social support and smoking (P . 0.05).
In a logistic regression analysis with forced entry of all
variables, those variables that showed significant relations in
our previous analyses were examined. Results of logistic
regression analyses are depicted in Table 3. Domestic violence, previous trauma experiences, anemia and cutaneous
leishmaniasis at baseline were the strongest of the predictors in multivariate analyses; women who experienced
domestic violence, previous trauma, anemia and cutaneous
Table 1 Mean and SD of continuous variables according to the mental
health status
Independent variables
Any mental
No mental
disorder
disorder
t; P
mean (SD)
mean (SD)
Women’s age
33.4 (9.5)
33.2 (9.4)
20.167; 0.868
Husband’s age
38.6 (10.7)
38.4 (11.4)
20.099; 0.921
Women education
1.3 (2.1)
1.7 (2.8)
0.827; 0.409
Husband education
3.6 (3.3)
5.4 (4.3)
3.069; 0.002
First marriage age
17.9 (2.9)
17.8 (3.2)
20.121; 0.904
First motherhood age
18.2 (4.9)
17.8 (6.3)
20.418; 0.676
Number of living children
4.5 (2.8)
3.7 (2.4)
22.290; 0.023
Number of household
6.3 (2.4)
5.6 (2.3)
22.172; 0.031
members
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Table 2 Prevalence of any mental disorders according to the independent
Table 3 Results of logistic regression analyses
categorical variables
Independent variables
Independent variables
Any mental disorder
Total
%
%
(n)
(n)
Socio-demographic variables
Economic situation
Low
36.4
(20)
22.3
Middle or high
22.9
(44)
77.7 (192)
(55)
4.027; 0.045
Family type
P
OR
95% CI
Education of husband
1.762
0.184
0.51
0.26
1.0
Economic situation
0.222
0.638
0.83
0.39
1.7
Number of living children
0.010
0.919
0.99
0.84
1.2
Number of household members
0.610
0.435
1.08
0.90
1.29
Anemia
3.988
0.046
1.07
1.01
3.03
C. leishmaniasis
3.998
0.047
2.15
1.25
7.31
Domestic violence
4.645
0.023
2.03
1.17
4.28
15.665
0.001
3.94
1.99
7.78
2.755
0.097
0.54
0.27
1.11
Previous trauma experience
15.4
Wald
X2; P
Expanded
18.4
(7)
Nuclear
27.3
(57)
84.6 (209)
(38)
Kurdish or Arabic
28.4
(52)
74.1 (183)
Turkish
18.1
(12)
25.9
1.312; 0.252
Ethnicity
Participation in decision-making
Hosmer and Lemeshow test: 0.961
2.307; 0.129
(64)
Physical health variables
Anemia
Yes
31.8
(34)
43.3 (107))
No
21.4
(30)
56.7 (140)
Normal
24.7
(37)
60.3 (149)
Overweight
27.6
(27)
39.7
(98)
Yes
53.3
(8)
6.1
(15)
No
24.1
(56)
3.96; 0.046
BMI
0.228; 0.633
C. Leishmaniasis
Mental health need
93.9 (232)
6.256; 0.012
0.999;0.318
Smoking
Yes
31.4
(16)
20.6
No
24.5
(48)
79.4 (196)
(51)
leishmaniasis were more likely to suffer from mental disorder than women who did not, with odds ratios of 2, 3.9,
1.1 and 1.2, respectively. Education of husband, economic
situation, participation in decision-making at home and
demographic variables such as number of living children
and size of household were not significant in the analyses.
While 25.9% of women diagnosed with any mental disorder,
only 4.7% of these women received mental health services.
Psychosocial variables
Discussion
History of previous
Main findings of this study
trauma
Yes
42.7
(38)
36.0
(89)
No
16.5
(26)
64.0 (158) 20.421; 0.001
Any domestic violence
Yes
33.6
(50)
60.3 (149)
No
14.3
(14)
39.7
(98) 11.437; 0.001
(74)
Physical violence
Yes
35.1
(26)
30.0
No
22.0
(38)
70.0 (173)
4.683; 0.030
Verbal violence
Yes
29.2
(21)
29.1
No
16.0
(28)
70.9 (175)
(72)
5.561; 0018
Economic violence
Yes
34.8
(24)
27.9
No
22.5
(40)
72.1 (178)
(69)
3.926; 0.048
Social support
Yes
23.4
(40)
69.2 (171)
No
31.6
(24)
30.8
1.837; 0.175
(76)
In our community sample, the prevalence of any mental disorder among 15– 49 years aged women was 25.9%. The
most common mental disorder was major depressive disorder (7.3%). Comorbid diagnoses were very high (67.2%).
Another notable result of our study was that although a
considerable proportion of women are diagnosed to have
any mental disorder, very few (4.7%) had ever received care
from mental health services. This alarming finding underscores the urgent need for improving the mental health services into the primary healthcare services. Although a
diverse array of potential risk factors emerged in bivariate
analyses, multivariate modeling demonstrated that previous
trauma experiences, having cutaneous leishmaniaisis and
anemia and experiencing domestic violence at baseline predicted the mental disorder; the odds were between 2 –7.8,
1.3 –7.3, 1.01 – 3.0 and 1.2 – 4.3, respectively.
Participation in
What is already known on this topic
decision-making
Yes
14.6
(18)
49.8 (123)
No
25.0
(31)
50.2 (124)
4.172; 0.041
Women are at heightened risk for common mental disorders: a female to male sex ratio of 1.5 to 2.0 is typical.2
WO M EN ’S M EN TA L H EALT H
Kilic, Küey and WHO reported that the prevalence of
mental disorders of women was 22.4, 20 and 25%, respectively, and majority of them had not contacted a carer in the
last year for psychological reasons.11,19,20 Reasons for not
seeking mental health treatment were inaccessibility of health
care, unawareness of mental health problems, stigmatization,
economic condition and cultural characteristics.21
The prevalence of pure major depressive disorder (7.3%)
and depression and anxiety disorder comorbidity was 11.3%
in this sample which was comparable to the prevalence
noted previously in studies conducted in community based
samples (i.e. 6.1 –12.9%).22 Depression is the most prevalent
women’s mental health problem and it is likely to be
accompanied by other psychological disorders which are
more common with anxiety disorders.1,9,13,23,24 Numerous
studies show that people exposed to traumatic life events are
at greater risk of psychological distress and psychiatric
disorders.20
The majority of the women (60.3%) experienced physical
(30.0%), verbal (29.1%) or economic (27.9%) domestic violence in their life in this study. Intimate partners (95.9%) are
most commonly the perpetrators of violence against women
as consistent with this study.25 Violence against women is a
public health problem in the world that has received
increased attention from researchers and health care providers.26,27 In the WHO study, the proportion of women who
had ever suffered physical violence by a male partner ranged
from 13% in Japan to 61% in provincial Peru.4 Around the
world, mental health problems and emotional distress are
common among women who have suffered partner violence.25 Although poor mental health can be a risk factor
for violence,28 – 30 mental disorders can result from assault
experiences.31,32 Good mental health may be a protective
factor against revictimization.33 Therefore, it is necessary to
set up community-based primary, secondary and tertiary
prevention services with collaboration with health-related
sectors such as education, social services, religion affairs and
media, and to give community health education for prevention of domestic violence.
Many studies have indicated that persons with a
cutaneous disease experience a high prevalence of psychiatric disorder.34,35 Cutaneous leishmaniasis is an infection
disease caused by a protozoan parasite and transmitted by
insect bites. The disease produces chronic ulcerative lesions
on exposed parts of the body, such as the face, arms and
legs. Cutaneous leishmaniasis leads to permanently disfiguring scars and creates a lifelong stigma.36,37 Cutaneous leishmaniasis has long been endemic in Sanliurfa and is called
‘beauty scar’. The patients with cutaneous leishmaniasis had
significantly higher anxiety and depression subscale scores
491
than the control groups, as consistent with our findings.
Developing sustainable control programme of cutaneous
diseases may be one of the effective measures for controlling mental disorders.
In this study, like mentioned above, another important
predictor was anemia. It is the most common and widespread nutritional disorder in the world. WHO estimates the
number of anemic people worldwide to be a staggering two
billion and that 50% of all anemia can be attributed to
iron deficiency. The negative consequences of iron
deficiency anemia on cognitive and physical health and work
productivity of adults have been well documented.18.
Although anemia has been recognized as a major health
problem for many years, a few study has been reported the
relation between mental disorders and anemia. Corwin and
his colleagues (2003) reported that there was a significant
relation between postpartum depression and anemia.38
What this study adds
This study draws together previous research on women’s
mental health, unmet mental health need and risk factors.
Mental health services for women have not been developed
and addressed in Turkey. Our findings make some contributions to the debate about mental health services. Mental
health awareness needs to be integrated into all elements of
health and social policy, health system planning and health
care delivery. These findings highlight the urgent need for
systematic development of community-based mental health
services in conjunction with primary healthcare services for
the screening, early identification and treatment of women
suffering from mental disorders and the improvement of
anemia and cutaneous leishmaniasis control programme.
Limitations of this study
The results of the present study should be interpreted in the
light of a number of limitations. First, as this study involved
a cross-sectional household interview survey, it may be
impossible to draw conclusions about the nature of the
putative causal relationship between mental disorders and
noted physical and psychosocial variables. Despite the limitation in the design of this study however, the results of this
study has immediate practical implications for improvement
of the assessment and intervention conditions for women
who have experienced a range of deprivation experiences.
The identification of risk and protective factors regarding
the mental disorders of women in community settings can
directly assist health professionals in identifying essential
interventions and setting priorities. Secondly, additional analytic epidemiological research is needed to replicate these
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J O U RN A L O F P U B L I C H E A LTH
findings and to investigate the potential underlying mechanisms that explain the differential association of mental disorders and predictive variables.
Acknowledgements
We would like to express our gratitude to all women who
gave their time for interviews and completing the forms.
Funding
Funding for this project was provided by the Harran
University Scientific Research Commission grant 472.
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