This paper describes the explanatory models of common mental disorders in primary care attendees in Goa, India. We found that somatic phenomena are overwhelmingly the most frequent presenting complaints and, amongst these, weakness/tiredness, sleep problems and aches/pains are dominant. However, psychological phenomena were relatively easily elicited from the majority of patients and cognitive phenomena such as thinking too much and emotional phenomena such as irritability/anger and loss of interest were the most frequent. The majority of respondents used psychological terms to label or describe their illness; 'tension' was by far the most common label. The vast majority of participants attributed their illness to psychosocial factors, rather than physical health factors. We observed very few gender differences apart from the different patterns of psychosocial difficulties.
Common mental disorders such as depression are already the leading neuropsychiatric cause of the burden of disease globally and this burden is projected to increase [14
]. Although there are effective treatments for these disorders which can be delivered in primary care settings [12
], there are a number of barriers to their implementation, notably the low recognition rates of the disorders in primary care settings. 'Somatization' has been cited as one reason to explain non-detection ([5
] and our study adds to the growing literature examining CMD through a contextual lens, to examine the extent to which 'somatization' occurs within the context of primary care in India viewed through the lens of the patients' explanatory models.
The findings of our study clearly demonstrate that even though people suffering from CMD predominantly complain of somatic symptoms, these are well recognized hall-mark features of depression and anxiety (for e.g. fatigue and sleep problems). Furthermore, psychological phenomena are easily elicited and the vast majority of patients admit to the psychosocial origins of their illness. Low mood is relatively a less common emotional phenomenon when compared with irritability and anhedonia. Overall, somatic symptoms are clearly located within in a larger bio-psychosocial framework (Figure); indeed, the 'cardinal features' of CMD as described in contemporary classifications were easily, and commonly, identified by our participants and a substantial proportion used the psychological construct of 'tension' to label their illness. Thus ‘tension” or “worry” appeared to represent the mediating illness category between adverse life events and social difficulties and somatic and mental phenomena. However, none of our subjects considered that they suffered from a 'mental disorder'.
A conceptual model of the casual pathways of CMD.
These findings confirm and build on findings that have been reported in previous studies conducted with women in the south Asian region. A study with 39 mothers suffering from post-natal depression, for example, reported that although a high proportion of mothers reported aches and pains, these were most commonly attributed to poor marital relationships and economic difficulties [10
]. Another study exploring the relationships between reproductive and mental health in 35 women with CMD reported that women expressed their mental health problems primarily through gynaecological complaints and sleep difficulties but strongly associated them with economic and interpersonal difficulties in their daily lives [11
]. In a study from a rural setting, women conceptualized mental health and depressive illness by the presence or absence of ‘pressure’ or ‘worries’, and they considered depressive illness to be directly linked to relational and economic factors in their lives [16
Similar findings are reported in a study in Chile where patients with mental disorders consulted the primary care doctor for physical complaints but did acknowledge presence of a psychological component to their physical problems [4
Our study, apart from extending the findings of community based studies on the explanatory models of CMD in South Asia to primary care settings, also adds to the scarce literature on the variations of these models by gender. Our principal observation is that men and women are very similar on symptom patterns, perhaps with the subtle difference that women were more forthcoming during the interviews and described their illness experiences with less probing. This may have implications in the nature of screening and assessment for detection of CMD in primary care. Both men and women described similar determinants linked to economic and interpersonal difficulties; the major differences we observed were that women being more likely to attribute their difficulties to marital conflicts which in some cases are associated with violence and alcohol abuse, and difficulties in managing work, while men were more likely to be concerned about old age, loss of earnings and financial difficulties. These are possibly reflective of the specific social roles that women and men are exposed to in a relatively patriarchal society. It is pertinent to note that the primary determinants cited by our participants in this qualitative study are entirely consistent with the epidemiological findings of the determinants of CMD in the South Asian region which has repeatedly demonstrated the influence of financial difficulties and intimate partner conflict and violence as risk factors [17
While interpreting the findings of this study a number of limitations have to be kept in mind. Firstly, since the patients who participated in the study were identified through a screening tool, there is a small risk of misclassification (small because, as indicated earlier, the tool questionnaire was validated and showed a high PPV at the cut-point used). Secondly, we have used only patient interviews to explore the explanatory models of CMD and these data could have been strengthened by evaluating the patient-PHC doctor encounter and the doctor explanatory models. Finally, the recording of somatic disorder diagnoses was not carried out systematically and thus the possible association of somatic symptoms with somatic disorders cannot be excluded.