The data reported here document a high lifetime prevalence of psychiatric disorders in South Africa, with 30% of respondents reporting a lifetime history of at least one of the DSM-IV/CIDI disorders considered in the survey. This is not as high an estimate as in the USA, where approximately half the population meets lifetime criteria for one or more DSM-IV/CIDI disorders (Demyttenaere, Bruffaerts, Posada-Villa, et al, 2004
). However, it is considerably higher than the estimate found in a recent survey of Yoruba-speaking Nigeria (Gureje, Lasebikan, Kola, et al, 2006
) and higher than in the majority of other countries that have participated in the first wave of the WHO World Mental Health Survey Initiative (Demyttenaere, Bruffaerts, Posada-Villa, et al, 2004
Examining the association of socio-demographic variables with psychiatric disorders provides an initial approach to understanding contributors to these prevalence rates. The associations of psychiatric disorder with gender (female gender associated with mood and anxiety disorders, male gender associated with substance use disorders) are consistent with those found in many other countries, whether industrialized or developing. Other findings may, however, point to the importance of local factors; the lack of an association between very low income and substance use disorders suggests the possibility that at least some disposable income is required for the purchase of alcohol (the most commonly abused substance in South Africa) and other substances.
It is notable, however, that there were few differences in lifetime prevalence, or age of onset of psychiatric disorders, by race. There was a lower lifetime prevalence of substance use disorders in Indians; this community includes a large proportion of Muslims, and proscription of alcohol use may play a role in explaining these data. Although there are clear links between race and access to health care in South Africa (Lalloo, Myburgh, Smith, et al, 2004
), other aspects of the relationship between race and psychiatric disorder may be more complex. Not the least important phenomenon to take into account may be the heterogeneity of the construct of race; although apartheid clearly disadvantaged blacks and advantaged whites, many local factors contributed to variance between individuals within these groups.
Examining prevalence estimates across cohorts and age of onset provides another approach to exploring the meaning of the prevalence rates found here. Prevalence estimates varied across cohorts for major depression, as in other surveys (WHO International Consortium in Psychiatric Epidemiology, 2000
; Kessler, Berglund, Demler, et al, 2005
). However, this phenomenon was not seen in GAD and PTSD, perhaps suggesting the importance of exposure to stress and trauma as risk factors for psychiatric disorders over many years in the local context. Particularly striking was the high prevalence (13.3%) and early age of onset (21 years) of substance use disorders. This pattern is much more pronounced in recent than earlier cohorts, suggesting that it is a relatively new problem in South Africa. The increasing prevalence of substance use disorders in successive cohorts has been found in many other countries (WHO International Consortium in Psychiatric Epidemiology, 2000
), but the increase generally was found to begin in earlier cohorts than seen here. South Africa was to some extent cut off from worldwide trends of many sorts during the apartheid years, and a rise in substance use disorders may have occurred later on, during democratization.
There are important limitations that should be noted, all of which are likely to make the lifetime prevalence estimates here conservative (Kessler, Berglund, Demler, et al, 2005
). People with psychiatric disorders have been shown in other countries to be less likely than others to participate in mental health surveys (Kessler, Wittchen, Abelson, et al, 1998
). There is a bias against reporting embarrassing behaviors and there are age-related underestimations of illness duration and failures to report past disorders. In addition, in view of time constraints, the interview did not inquire about several prevalent conditions.
Another important limitation of the survey is the lack of clinical validation of the CIDI in the South African study. While results were reassuring in CIDI clinical validation studies carried out in conjunction with the WMH surveys in the USA (Kessler, Berglund, Demler, 2005
) and Europe (Haro, Arbabzadeh-Bouchez, Brugha, et al
, 2006), the cultural heterogeneity of the South African subjects might have impacted adversely on the diagnostic accuracy of the instrument. The high lifetime prevalence of agoraphobia without panic here, and the variability in age of onset of major depression and GAD, for example, may warrant caution. Perhaps some of those captured within the category of agoraphobia suffer from the avoidant symptoms of PTSD, from specific phobia (which was not included in the South African study, and which is usually the most prevalent anxiety disorder, and the one with earliest onset), or from realistic fears of going outside. Overestimates of agoraphobia have similarly occurred in previous epidemiological work (Horwath, Lish, Johnson, et al, 1993
; Wittchen, Zhao, Abelson, et al, 1996
Nevertheless, the high lifetime prevalence estimates for psychiatric disorders found here are broadly consistent with previous work in South Africa. A community prevalence study of psychiatric morbidity in a rural coloured village found a prevalence of psychiatric morbidity of 27.1%, with the majority of cases diagnosed with depressive or anxiety disorder (Rumble, Swartz, Parry, et al, 1996
). A prevalence study in a township primary health care clinic found that depression (37%), PTSD (20%), and somatization disorder (18%) were the most common diagnoses (Carey, Stein, and Zungu-Dirwayi, 2003
Such data have been criticized by those who argue that distress in the developing world should not be conflated with the presence of psychiatric disorders, and who question the applicability of the DSM classification system to non-Western countries (Kirmayer, 1991
). There is growing acceptance, however, that psychiatric disorders, as classified by DSM-IV and diagnosed by instruments such as the CIDI, are accompanied by significant social and occupational impairment. Furthermore, research on pathogenesis and intervention has demonstrated that such disorders are associated with psychobiological dysfunction and that efficacious and cost-effective treatments are available, even in a developing world context (Stein and Gureje, 2004
; Chisholm, Sanderson, Ayuso-Mateos, et al, 2004
). This is not to minimize the potentially important effects of cultural context on the experience and expression of psychiatric disorders.
The high estimated lifetime prevalence and relatively early onset of psychiatric disorders noted here, taken together with data in the literature on associated impairment and cost-efficacy of treatment, and with the growing acceptance that those with mental illness have a right to treatment, has important policy implications. Rigorous data on the proportion of the health budget spent on mental health services in the South African setting are not readily available, but there is consensus that a gross lack of parity exists, with significant under-funding of mental health services and research (Seedat, Emsley, and Stein, 2004
). We hope that the data reported here take a first step in documenting a level of need for care that is sufficiently compelling to provide impetus for changes in mental health policy in South Africa, with an appropriate increase in funding for mental health services.