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Prevalence of psychological distress and associated factors in urban hospital outpatients in South Africa.

Common mental disorders such as depressive and anxiety disorders are classified in the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10), (1) as 'neurotic, stress-related and somatoform disorders' and 'mood disorders'. Common mental disorders (CMDs), which include depression, anxiety and somatoform disorders, make a significant contribution to the burden of disease and disability in low- and middle-income countries (LMICs). (2,3) These conditions are responsible for up to 10% of the total global disease burden. (4) Based on recent findings from World Health Organization World Mental Health surveys on the global burden of mental disorders, the inter-quartile range (IQR: 25th-75th percentiles) of lifetime Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV) disorder prevalence estimates (combining anxiety, mood, externalising and substance use disorders) was 18.1-36.1%. (5) At least one-third of all patients seen in primary care in LMICs present with CMDs. The majority of these are not recognised or are ineffectively treated. (4) Although depressive and anxiety disorders are classified as separate diagnostic categories in the ICD-10, (1) the concept of CMDs is valid for public health interventions owing to the high degree of co-morbidity between these disorders in primary care and the similarity in epidemiological profiles and treatment responsiveness. (6)

Various studies have identified high prevalence rates of CMDs among primary healthcare patients in LMICs, e.g. 23% probable cases in Nicaragua, (7) 21.3% psychiatric disorders in Nigeria, (8) 23% major depression, 24% panic disorder and 29% generalised anxiety disorder in Lesotho, (9) and a prevalence of generalised anxiety and depressive disorders of 23.9% in a community-based sample in South Africa. (10)

Factors associated with CMDs of primary care patients in LMICs include older age, (8,10) female gender, (8) being widowed, separated or divorced (8,10) or unemployed, (10,11) low socio-economic status, (10,12,13) low social capital, (13) substance use such as smoking (14) and alcohol problems, (15) and chronic medical illness (16) such as type 2 diabetes mellitus, (17) hypertension, (18) peptic ulcer, (19) lower back pain (20) and communicable illnesses such as tuberculosis. (21)

Increasing emphasis has been placed on the detection and treatment of CMDs, particularly among patients seen in primary care settings. (4) Hospital settings are a particularly valuable point of contact for the delivery of brief interventions, because large numbers of patients attend these facilities each year. The fact that little information exists about CMDs or psychological distress among hospital outpatients in South Africa prompted the study.

Aim of the study

The aim of this study was to assess the prevalence of psychological distress and associated factors among outpatients in an urban hospital in South Africa.

Methods

Sample and procedure

The sample included 1 532 subjects (56.4% men and 43.6% women) consecutively selected from different hospital outpatient departments. Universal screening of all presenting outpatients was utilised, whereby all consecutive clients visiting outpatient departments were interviewed. The study protocol was approved by the Research Ethics Committee of the University of Limpopo (Medunsa Campus). Informed consent was obtained from the patients who participated.

Measures

Demographic characteristics. A researcher-designed questionnaire was used to record demographic information on participants' age, gender, educational level, marital status, income and place of residence (urban or rural).

The Kessler Psychological Distress Scale (K-10) was used to measure global psychological distress, including significant pathology that does not meet formal criteria for a psychiatric illness. (22, 23) This scale measures symptoms over the preceding 30 days by asking: 'In the past 30 days, how often did you feel: nervous; so nervous that nothing could calm you down; hopeless; restless or fidgety; so restless that you could not sit still; depressed; that everything was an effort; so sad that nothing could cheer you up; worthless; tired out for no good reason?' The frequency with which each of these items was experienced was recorded using a 5-point Likert scale ranging from 'none of the time' to 'all the time. This score was then summed, with increasing scores reflecting an increasing degree of psychological distress. The K-10 has been shown to capture variability related to nonspecific depression, anxiety and substance abuse, but does not measure suicidality or psychoses. (24) This scale serves to identify individuals who are likely to meet formal definitions for anxiety and/or depressive disorders, as well as to identify individuals with sub-clinical illness who may not meet formal definitions for a specific disorder. (22) It is increasingly used in population mental health research and has been validated in multiple settings (25) including among pregnant women (26) and HIV-positive individuals in South Africa. (27) We examined the K-(10) scale using ordinal categories for low, moderate, high and very high psychological distress (scores of 10-19, 20-24, 25-29 and [greater than or equal to] 30, respectively) and as a binary variable comparing scores of 0-29 versus [greater than or equal to] 30. The internal reliability coefficient for the K-10 in this study was Cronbach alpha = 0.89.

Alcohol consumption. The 10-item Alcohol Disorder Identification Test (AUDIT) (28) assesses alcohol consumption level (3 items), symptoms of alcohol dependence (3 items), and problems associated with alcohol use (4 items). In South Africa a standard drink is 12 g alcohol. Because the AUDIT is reported to be less sensitive at identifying risky drinking in women than in men, (29) the cut-off point of binge drinking for women (4 units) was reduced by one unit compared with men (5 units), as recommended by Freeborn et al. (29) Responses to items on the AUDIT are rated on a 4-point Likert scale from 0 to 4, for a maximum score of 40 points. Higher AUDIT scores indicate more severe levels of risk; scores of 8 or more indicate a tendency to problem drinking. Cronbach alpha for the AUDIT in this sample was 0.88, indicating excellent reliability.

Tobacco use. Two questions were asked about the use of tobacco products: (i) 'Do you currently use one or more of the following tobacco products (cigarettes, snuff, chewing tobacco, cigars, etc.)?' (response options were 'yes' or 'no'); and (ii) 'In the past month, how often have you used one or more of the following tobacco products (cigarettes, snuff, chewing tobacco, cigars, etc.)?' (response options were once or twice, weekly, almost daily and daily).

Perceived general health. Participants were asked: 'In general, would you say your health is: excellent, very good, good, fair or poor?' This measure was categorised based on participant response (very good = excellent/very good, good = good, and poor = fair/ poor).

Patients were also given a list of chronic and communicable illnesses such as hypertension, diabetes and sexually transmitted diseases (STDs), and asked to indicate which of them they had been diagnosed with.

Data analysis

Data were analysed using the Statistical Package for the Social Sciences (SPSS) for Windows software application programme version 17.0. Frequencies, means and standard deviations (SDs) were calculated to describe the sample. Predictors of severe psychological distress were identified using logistic regression analyses. Following each univariate regression, multivariable regression models were constructed. Independent variables from the univariate analyses were entered into the multivariable model if significant at a level of p<0.05. Logistic regression was conducted for men and for women separately. Cases with missing data were excluded from the multivariable models. For each model, the [R.sup.2] are presented to describe the amount of variance explained by the multivariable model. Probability below 0.05 was regarded as statistically significant.

Results

Sample characteristics

Of the 1 713 hospital outpatients approached, 1 532 agreed to participate (89.4% response rate). The final sample included 1 532 (56.4% men and 43.6% women) consecutively selected from different hospital outpatient departments. Their mean age was 36.1 years (SD 11.6, range 18-77 years). Almost two-thirds (63.8%) of the participants had never been married, almost half (48%) had grade 12 or higher education, 32.6% had a formal salary as main household income, and 80.1% lived in an urban area. Forty per cent of the hospital outpatients had chronic conditions and 60% were general hospital outpatients, 57.8% rated their health as excellent or very good, 24.2% used tobacco products daily or almost daily, and 34.9% scored 8 or more on the AUDIT indicating hazardous or harmful alcohol use. With regard to previously diagnosed conditions, 30.2% reported migraine headaches, 26.1% lower back pain, 19.3% hypertension, 17.3% arthritis, 17.3% stomach ulcer, 8.3% diabetes, 7.6% STD, 7.3% tuberculosis and 7.3% depression (Table 1).

Psychological distress

Overall 17.1% of the patients had scores on the K-10 indicating severe distress; this figure was significantly higher in women (19.4%) compared with men (15.5%). Moderate distress was reported by 14%, mild distress by 18.6% and no significant distress by 50.3% (Table 2).

Predictors of psychological distress

Univariate analyses showed that among men, lower education, no income, poor self-rated health status, daily or almost daily tobacco use, and having been diagnosed with a stomach ulcer, migraine headache, lower back pain, high cholesterol, arthritis or tuberculosis were associated with severe psychological distress; and among women, severe psychological distress was associated with older age, lower education, no income, being a chronic disease hospital outpatient, poor self-rated health status, and having been diagnosed with hypertension, a sexually transmitted disease, migraine headache, lower back pain, high cholesterol, diabetes or tuberculosis. Multivariable analysis showed that among men no income, poor self-rated health status, daily or almost daily tobacco use, and having been diagnosed with migraine headache or tuberculosis remained significantly associated with severe psychological distress, and that for women lower education, no income, and having been diagnosed with a sexually transmitted disease, stomach ulcer or migraine headache remained significantly associated with severe psychological distress (Table 3).

Discussion

A high prevalence of severe (17.1%) and moderate (14.0%) psychological distress was identified in this study of a large sample of hospital outpatients in South Africa. This finding is comparable with prevalence rates of psychological distress or CMDs in other LMICs (Nicaragua 23%, (7) Nigeria 21.3%, (8) Lesotho major depression 23%, panic disorder 24%, and generalised anxiety disorder 29%). (9)

In concurrence with other studies this study found an association between severe psychological distress and female gender. (8) low socio-economic status (lower education, no income, (10,11,13) daily or almost daily tobacco use, (14,30) and having been diagnosed with chronic diseases including stomach ulcer, (19) migraine headache, (19) lower back pain, (20) hypertension, (18) and communicable diseases including tuberculosis (21) and STDs. (31) In a large Canadian community study, sexually transmitted infections (STIs) among women also increased the risk of depression. (32) The diagnosis of an STI may contribute to the development of depression. (32)

Study limitations

Caution should be taken when interpreting the results of this study because of certain limitations. As this was a cross-sectional study, causality between the compared variables cannot be concluded. A further limitation was that all variables were assessed by self-report and desirable responses may have been given.

Conclusion

The study found a high prevalence of psychological distress among hospital outpatients in South Africa. Brief psychological therapies for adult patients with anxiety, depression or mixed common mental health problems treated in hospital outpatient departments are indicated. (33) Accurate diagnosis of co-morbid depressive and anxiety disorders in patients with chronic medical illness is essential in understanding the cause and optimising the management of somatic symptom burden. (34)

Acknowledgement. The study was funded by the Directorate General for Development Cooperation (DGDC) through the Flemish Interuniversity Council (VLIR-UOS).

References

(1.) World Health Organization. International Statistical Classification of Diseases and Related Health Problems. 10th revision (ICD-10), version for 2007. Geneva: WHO, 2007.

(2.) World Health Organization. World Health Report 2001, Mental Health: New Understanding, New Hope. Geneva: WHO, 2001.

(3.) Lopez DA, Mathers DC, Ezzati M, Jamison TD, Murray JLC. Global Burden of Disease and Risk Factors. New York: Oxford University Press/World Bank, 2006.

(4.) Siddiqi K, Siddiqi N. Treatment of common mental disorders in primary care in low- and middle-income countries. Trans R Soc Trop Med Hyg 2007;101(10):957-958.

(5.) Kessler RC, Aguilar-Gaxiola S, Alonso J, et al. The global burden of mental disorders: An update from the WHO World Mental Health (WMH) Surveys. Epidemiologia e Psichiatria Sociale 2009;18(1):23-33.

(6.) Patel V, Simon G, Chowdhary N, Kaaya S, Araya R. Packages of care for depression in low- and middle-income countries. PLoS Med 2009;6(10):e1000159. [doi:10.1371/journal. pmed.1000159]

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(8.) Abiodun OA. A study of mental morbidity among primary care patients in Nigeria. Compr Psychiatry 1993;34(1):10-13.

(9.) Hollifield M, Katon W, Morojele N. Anxiety and depression in an outpatient clinic in Lesotho, Africa. Int J Psychiatry Med 1994;24(2):179-188.

(10.) Bhagwanjee A, Parekh A, Paruk Z, Petersen I, Subedar H. Prevalence of minor psychiatric disorders in an adult African rural community in South Africa. Psychol Med 1998;28(5):1137 1147.

(11.) Reeler AP, Williams H, Todd CH. Psychopathology in primary care patients: a four year study in rural and urban settings in Zimbabwe. Cent Afr J Med 1993;39(1):1-7.

(12.) Pillay AL, Sargent CA. Relationship of age and education with anxiety, depression, and hopelessness in a South African community sample. Percept Mot Skills 1999;89:881-884.

(13.) Myer L, Stein DJ, Grimsrud A, Seedat S, Williams DR. Social determinants of psychological distress in a nationally-representative sample of South African adults. Soc Sci Med 2008;66(8):1828-1840.

(14.) Massak A, Graham K. Is the smoking-depression relationship confounded by alcohol consumption? An analysis by gender. Nicotine Tob Res 2008;10(7):1231-1243.

(15.) Sullivan LE, Fiellin DA, O'Connor PG. The prevalence and impact of alcohol problems in major depression: a systematic review. Am J Med 2005;118(4):330-341.

(16.) Katon WJ. Epidemiology and treatment of depression in patients with chronic medical illness. Dialogues Clin Neurosci 2011;13(1):7-23.

(17.) Mezuk B, Eaton WW, Albrecht S, Golden SH. Depression and type 2 diabetes over the lifespan: a meta-analysis. Diabetes Care 2008;31(12):2383-2390.

(18.) Grimsrud A, Stein DJ, Seedat S, Williams D, Myer L. The association between hypertension and depression and anxiety disorders: results from a nationally-representative sample of South African adults. PLoS One 2009;4(5):e5552.

(19.) Culpepper L. Generalized anxiety disorder and medical illness. J Clin Psychiatry 2009;70(Suppl 2):20-24.

(20.) Demyttenaere K, Bruffaerts R, Lee S, et al. Mental disorders among persons with chronic back or neck pain: results from the World Mental Health Surveys. Pain 2007;129(3):332-342.

(21.) Aghanwa HS, Erhabor GE. Demographic/socioeconomic factors in mental disorders associated with tuberculosis in southwest Nigeria. J Psychosom Res 1998;45(4):353-360.

(22.) Kessler RC, Andrews G, Colpe LJ, et al. Short screening scales to monitor population prevalences and trends in nonspecific psychological distress. Psychol Med 2002;32:959-976.

(23.) Kessler RC, Barker PR, Colpe LJ, et al. Screening for serious mental illness in the general population. Arch Gen Psychiatry 2003;60(2):184-189.

(24.) Brooks RT, Beard J, Steel Z. Factor structure and interpretation of the K10. Psychol Assess 2006;18(1):62-70.

(25.) Andrews G, Slade T. Interpreting scores on the Kessler Psychological Distress Scale (K10). Aust N Z J Public Health 2001;25:494-497.

(26.) Spies G, Stein DJ, Roos A, et al. Validity of the Kessler 10 (K-10) in detecting DSM-IV defined mood and anxiety disorders among pregnant women. Arch Womens Ment Health 2009;12(2):69-74.

(27.) Spies G, Kader K, Kidd M, et al. Validity of the K-10 in detecting DSM-IV-defined depression and anxiety disorders among HIV-infected individuals. AIDS Care 2009;21(9):1163-1168.

(28.) Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG. AUDIT: The Alcohol Use Disorders Identification Test. Guidelines for Use in Primary Care. Geneva: World Health Organization, Department of Mental Health and Substance Dependence, 2001 (WHO/MSD/MSB/01.6a, 2001).

(29.) Freeborn DK, Polen MR, Hollis JF, Senft RA. Screening and brief intervention for hazardous drinking in an HMO: effects on medical care utilization. J Behav Health Serv Res 2000;27(4):446-453.

(30.) Lawrence D, Mitrou F, Zubrick SR. Non-specific psychological distress, smoking status and smoking cessation: United States National Health Interview Survey 2005. BMC Public Health 2011;11(1):256.

(31.) Owe-Larsson B, Sall L, Salamon E, Allgulander C. HIV infection and psychiatric illness. Afr J Psychiatry 2009;12(2):115-128.

(32.) Chen Y, Wu J, Yi Q, Huang G, Wong T. Depression associated with sexually transmitted infection in Canada. Sex Transm Infect 2008;84(7):535-540.

(33.) Cape J, Whittington C, Buszewicz M, Wallace P, Underwood L. Brief psychological therapies for anxiety and depression in primary care: meta-analysis and meta-regression. BMC Med 2010;8:38.

(34.) Katon W, Lin EH, Kroenke K. The association of depression and anxiety with medical symptom burden in patients with chronic medical illness. Gen Hosp Psychiatry 2007;29(2):147-155.

Karl Peltzer, PhD

HIV/AIDS/STI and TB (HAST), Human Sciences Research Council, Pretoria, and Department of Psychology, University of Limpopo (Turfloop Campus), Limpopo

Supa Pengpid, DrPH

Linda Skaal, DrPH

Department of Health System Management and Policy, University of Limpopo (Medunsa Campus), Pretoria

Table 1. Sample characteristics

                         Men (N=864, 56.4%)  Women (N=668, 43.6%)

Sample characteristics   N        %          N         %

Age (yrs)
  18 - 24                138      16.0       120       18.1
  25 - 34                280      32.6       248       37.3
  35 - 44                200      23.3       169       25.5
  45 - 54                153      17.8       94        14.2
  [greater than or
    equal to]55          89       10.3       33        5.0

Marital status
  Never married          520      61.8       435       66.2
  Married/cohabitating   289      34.3       183       27.8
  Separated/divorced/
    widowed              32       3.8        29        5.9

Education
  [less than or equal
    to] Grade 7          125      14.6       82        12.4
  Grade 8 - 11           335      39.0       249       37.6
  [greater than or
    equal to] Grade 12   399      46.4       332       50.1

Main household income
  Formal salary          325      37.8       172       25.9
  Family member
    contributions        235      27.4       250       37.7
  Social grants          68       7.9        76        11.4
  Other                  128      14.9       63        9.5
  No income              103      12.0       103       15.5

Urban residence          693      80.8       523       79.1

Rural residence          165      19.2       138       20.9

Chronic hospital
  outpatient             304      35.3       311       46.8
General hospital
  outpatient             556      64.7       354       53.2
Very good v. poor
  health status          498      58.0       383       57.6
Daily or almost daily
  tobacco use            288      33.4       82        12.3
Hazardous or harmful
  alcohol use            401      46.6       131       19.7

Illness conditions
  (ever diagnosed)
  Hypertension           148      17.2       145       21.9
  High cholesterol       21       2.5        23        3.5
  Diabetes               74       8.6        52        7.9
  Cancer                 17       2.0        31        4.7
  Depression             57       6.7        50        7.6
  Migraine headache      201      23.5       258       39.2
  Stomach ulcer          125      14.6       138       21.0
  Asthma                 29       3.4        40        6.1
  Arthritis              125      14.6       136       20.6
  Tuberculosis           74       8.6        37        5.6
  Lower back pain        207      24.4       187       28.4
  STD                    70       8.2        45        6.8

                         Total (N=1 532)

Sample characteristics   N       %

Age (yrs)
  18 - 24                258     16.9
  25 - 34                528     34.6
  35 - 44                369     24.2
  45 - 54                247     16.2
  [greater than or
    equal to]55          122     8.0

Marital status
  Never married          955     63.8
  Married/cohabitating   472     30.5
  Separated/divorced/
    widowed              58      5.7

Education
  [less than or equal
    to] Grade 7          207     13.6
  Grade 8 - 11           584     38.4
  [greater than or
    equal to] Grade 12   731     48.0

Main household income
  Formal salary          497     32.6
  Family member
    contributions        485     31.8
  Social grants          144     9.5
  Other                  191     12.5
  No income              206     15.5

Urban residence          1218    80.1

Rural residence          303     19.9

Chronic hospital
  outpatient             615     40.3
General hospital
  outpatient             910     59.7
Very good v. poor
  health status          882     57.8
Daily or almost daily
  tobacco use            370     24.2
Hazardous or harmful
  alcohol use            532     34.9

Illness conditions
  (ever diagnosed)
  Hypertension           293     19.3
  High cholesterol       44      2.9
  Diabetes               126     8.3
  Cancer                 48      3.2
  Depression             107     7.0
  Migraine headache      459     30.2
  Stomach ulcer          263     17.3
  Asthma                 69      4.6
  Arthritis              262     17.3
  Tuberculosis           111     7.3
  Lower back pain        394     26.1
  STD                    115     7.6

Table 2. Levels of psychological distress of male and female
participants

                                 K-10 score   Total (N=1 532) (%)

No significant distress          10 - 19      50.3
Mild distress                    20 - 24      18.6
Moderate distress                25 - 29      14.0
Severe distress                  30 - 50      17.1
  Total K-10 score (mean (SD))                21.5 (8.9)

                                 Men (N=864) (%)   Women (N=668) (%)

No significant distress          53.5              46.0
Mild distress                    17.8              19.6
Moderate distress                13.2              15.0
Severe distress                  15.5              19.4
  Total K-10 score (mean (SD))   20.9 (8.7)        22.4 (9.2) *

* t=-3.14; p<0.001.

Table 3. Predictors of severe psychological distress

                                            Men

Predictors             Crude OR (95% CI)        Adjusted OR (95% CI)
                       ([dagger])               ([dagger])
                                                ([double dagger])

Age                    1.01 (0.99 - 1.02)       --

Married/
cohabitating v. Not    0.97 (0.64 - 1.47)       --

[less than or equal
to] Grade 7 or less    1.00                     1.00

Grade 8 - 11           0.57 (0.34 - 0.97) *     0.85 (0.47 - 1.55)

[greater than or       0.40 (0.23 - 0.68) ***   0.79 (0.42 - 1.47)
equal to] Grade 12                              1.00

No income              1.00                     0.57 (0.33 - 0.99) *

Formal salary          0.42 (0.26 - 0.69) ***   1.08 (0.62 - 1.88)

Family
contributions          0.64 (0.39 - 1.05)       0.69 (0.28 - 1.69)

Social grants          0.63 (0.28 - 1.45)

Chronic v. general
outpatient             1.14 (0.76 - 1.71)       --

Very good v. poor
health status          0.38 (0.26 - 0.58) ***   0.51 (0.32 - 0.80) **

Daily or almost
daily tobacco use      1.79 (1.20 - 2.67) **    1.81 (1.17 - 2.80) **

Hazardous or
harmful drinking       1.27 (0.86 - 1.89)       --

Hypertension           1.50 (0.92 - 2.45)       --

Sexually
transmitted disease    1.56 (0.84 - 2.93)       --

Stomach ulcer          2.26 (1.39 - 3.67) ***   1.29 (0.69 - 2.43)

Migraine headache      3.86 (2.55 - 5.87) ***   3.38 (2.08 - 5.48) ***

Lower back pain        2.29 (1.50 - 3.49) ***   1.32 (0.81 - 2.17)

Asthma                 1.98 (0.82 - 4.80)       --

High cholesterol       2.83 (1.04 - 7.66) *     1.83 (0.57 - 5.90)

Diabetes               1.35 (0.71 - 2.57)       --

Arthritis              2.16 (1.33 - 3.50) **    1.46 (0.84 - 2.53)

Tuberculosis           2.37 (1.36 - 4.15) **    0.56 (0.32 - 0.80) **

Cancer                 1.84 (0.58 - 5.81)       --

                                          Women

Predictors             Crude OR (95% CI)        Adjusted OR (95% CI
                       ([dagger])               ([dagger])([section])

Age                    1.03 (1.01 - 1.05) **    0.99 (0.96 - 1.02)

Married/
cohabitating v. Not    1.11 (0.70 - 1.75)       --

[less than or equal
to] Grade 7 or less    1.00                     1.00

Grade 8 - 11           0.29 (0.16 - 0.52) ***   0.54 (0.26 - 1.13)

[greater than or       0.22 (0.12 - 0.40) ***   0.34 (0.16 - 0.74) **
equal to] Grade 12

No income              1.00                     1.00

Formal salary          0.34 (0.19 - 0.58) ***   0.53 (0.28 - 0.98) *

Family
contributions          0.16 (0.09 - 0.27) ***   0.25 (0.13 - 0.48) ***

Social grants          0.28 (0.12 - 0.64) **    0.32 (0.12 - 0.83) *

Chronic v. general
outpatient             1.55 (1.02 - 2.37) *     0.91 (0.55 - 1.49)

Very good v. poor
health status          0.35 (0.23 - 0.54) ***   0.60 (0.36 - 1.02)

Daily or almost
daily tobacco use      1.69 (0.97 - 2.97)       --

Hazardous or
harmful drinking       0.67 (0.38 - 1.18)       --

Hypertension           1.81 (1.13 - 2.90) *     1.04 (0.55 - 1.96)

Sexually
transmitted disease    2.93 (1.50 - 5.70) **    3.97 (1.79 - 8.78) ***

Stomach ulcer          3.46 (2.20 - 5.42) ***   1.80 (1.05 - 3.10) *

Migraine headache      3.57 (2.30 - 5.52) ***   2.24 (1.33 - 3.76) **

Lower back pain        3.00 (1.94 - 4.62) ***   1.66 (0.97 - 2.83)

Asthma                 2.00 (0.95 - 4.21)       --

High cholesterol       3.97 (1.57 - 10.01) **   1.58 (0.46 - 5.44)

Diabetes               2.23 (1.16 - 4.31) *     2.00 (0.86 - 4.68)

Arthritis              1.40 (0.86 - 2.28)       --

Tuberculosis           2.87 (1.42 - 5.81) **    2.13 (0.92 - 4.95)

Cancer                 0.94 (0.35 - 2.53)       --

* p=0.05; ** p =0.01; *** p =0.001.

([dagger]) Using forward logistic regression selection of variables.

([double dagger]) For men Hosmer and Lemeshow chi-square = 10.77,
p=0.215; Cox and Snell [R.sup.2] =0.11; Nagelkerke [R.sup.2] =0.19.

([section]) For women Hosmer and Lemeshow chi-square = 17.16, p=0.029;
Cox and Snell [R.sup.2] =0.19; Nagelkerke [R.sup.2] =0.31.

OR = odds ratio; CI = confidence interval.
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Author:Peltzer, Karl; Pengpid, Supa; Skaal, Linda
Publication:South African Journal of Psychiatry
Article Type:Report
Geographic Code:6SOUT
Date:Feb 1, 2012
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