Mental Illness among Indian Women Bhargavi V Davar

Community surveys, done roughly between the 1970s and the 1990s, provide information on the socio-demographic profile of a mentally ill person in Indian communities. However, these studies do not treat the aspect of gender nor are there other independent studies on women and mental illness. In order to fill a noticeable lacuna in women's health studies, information about mental illness in Indian women has been obtained from the primary data available from these studies. As gender has been used as a socio-demographic variable in all the studies, it was possible to cull out gender relevant data and re-analyse them from the gender perspective. This work is a secondary analysis.

IN the mental health scenario, professional and institutional attention has so far not focused on the mental health needs of Indian women. Planning for mental health in the country, and also, planning for women's health have altogether neglected the question of the mental health of women. In the west, since Phyllis Chester's (1972) classic work on Women and Madness, at least two dozen professional studies and various committee and planning reports, including a rcccnt report (Linderstein et al 1993)of WHO have been published. However, in our own context, we are yet to see a comprehensive academic work in the area, not to mention the complete lack of policy or pro^iamme addressing the issue, though scattered material, anecdotal and academic, are available that requires reviewing and analysis.

This paper is one such attempt and tries to provide some in format ion on the occurrence of mental illness among women. Early epidemiological studies in the country, done during the 1970s and the 1980s, give us a picture of the mentally ill in the community. These studies, totalling about a dozen or so» relate mental illness to several socio-dcmographic variables, such as marriage, education, age, income, etc, so that, in general, the social profile of a mental ly ill person may be obtained. These studies, not being gender-specific, gloss over gender differences in the expression of mental i 11 ness. That is, even though the studies provide a general idea about the socio-demographic characteristics of the mentally ill in the community, they do not give information about gender differences in the expression, prevalence,causeorcourseof mental illness,

Gender has been used as a variable in many of these studies. Therefore it was possible to approach these studies from the perspective of gender, culling out gender-relevant information from them, and making independent associations with the other variables, such as marr iage, age and education. This approach, being a secondary analysts, has obvious limitations, such as discrepancies in methodology, the diagnostic categories used, the varying cultural contexts of the different studies, etc. However, I have

adopted criteria that will overcome at least some of these problems. For example, only those studies with comparable methodologies and diagnostic categories have been used. It has been assumed that the different studies from different parts of the country are representative and will give an approximate, if not accurate, picture of a mentally ill woman in our culture. From this analysis, it has been possible to obtain information about mental illness among women and respond to important questions such as the frequency of prevalence of mental illness among women and their proneness to certain types of disorders. I have been able, to a limited extent, to associate the occurrence of mental illness in women with other socio-demographic variables such as marital status, age, education, work, etc.

GENDER IN HOSPITAL AND EPIDEMIOLOGICAL

STUDIES

Some of the studies, such as those by Brij Mohan (1970) , Sethi et al (1978) , Bhattacharya and Vyas (1969), Weismann and Klerman (1977), all record a male preponderance of psychiatric disorders, particularly depression. Bhattacharya and Vyas observed an equal number of male and female deprcss ives in their sample . Weismann and Klerman also noted a greater prevalence of mental illness among men. This trend is not in keeping with studies from the west, where, it has been noted especially in the ease of depressive disorders that tSwomcn predominate in all countries and all time periods*' [Guttentag 1980:731.

It is noteworthy that the above studies have been based on hospital samples and not community samples. These studies have used data on utility as if they were prevalence data, which is highly questionable, especially in the Indian context. In the west, there is parity of access to health care by both the sexes, and so there is some justification in subjecting hospital based samples to pre-valence analysis. Comparisons of community survey rates of mental illness and hospital rates do not grossly differ in the western context. But, in our country, there is gross

gender based inequity of access especially to hospital care and so, making any conclusion about the comparative prevalence of mental illness in the two sexes based upon utility data gathered from hospital samples is both methodologically questionable and politically misleading.

Such a methodolog ica l ly dub ious conclusion is politically misleading for the following reason: The naive explanation some of the above studies offer for the supposedly greater prevalence of mental illness among men is that it is men who carry the burden of responsibility in a patriarchal system, with other family members, such as women,contributing very little. Sethi (1978), for example, explains the greater frequency of illness among men in his study by noting that "the obligation and responsibilities that a male must fulfil are full of challenge and stress" (p 204). Venkoba Rao observes, "the patriarchal system of the population may possibly explain" the male preponderance in his sample of deprcssives. By making this assumption, these studies altogether ignore crucial issues women's movements have been raising such as, the unequal decision-making power, unequal work distribution, work overload, unpaid labour, rigid role functions and stereotyping, all of which are dehumanising and stressful for women. These studies thereby provide a facile and easy explanation for the greater prevalence of mental illness among men, showing a distinct gender bias in their supposedly professional perspective.

It is not the case that the point about inequity of access to health care by both the sexes have altogether escaped some of these authors. Sethi (1978), for example, writes, "While it has been reported thai a higher percentage of male population registered at psychiatric facilities in India, it is by no means indicative of a higher morbidity in males. Lack of education, superstitions and reluctance on the part of the womenfolk and the social stigma and bleak chances of matrimonial placement in our culture are significant determinants" <p 206). But, even in this caveat that the author adds, we sec the responsibility for being mentally well

Economic and Political Weekly November 11, 1995 2879

and seeking menial health care is somehow thrust upon the woman. The author clearly implies that if women do not seek mental health care, it is because of their "lack of education, superstitions and reluctance", whereas the social reality of most women is that decision-making about her own health needs rarely rests with her.

As all these studies are based on hospital data, thev have not been considered in the analyses of the prevalence of mental illness in women. Instead, we turn our attention to the available community surveys.

E p i d e m i o l o g i c a l s t u d i e s s h o w the prevalence rates of mental disorders in the community to vary from between 23.79 |Dube 197()| per thousand and 129 per thousand [Chakraborty I990| . A perfunctory note of explanation is invariably appended to each of these studies, citing the cultural, demographic, methodological and diagnostic variance of the studies. Rural and urban samples show variance; some studies include all kinds of disorders, such as suicide, psychopathy, alcoholism, drug addiction, speech and behaviour disorders of children, etc, while others do not; criteria of inclusion or 'caseness' varies from study to study, depending on the diagnostic tools used and the method adopted for case-identification. With an almost audible sigh of helplessness in deciding how useful these data are and how exactly one must treat them, it is now understood that mental i l lness in the community is of the order of 11 per cent, of w h i c h 3 per cent require "act ive rehabilitation" and 1 per cent require hospitalisation. Table I shows different studies in the country since 1970, and the prevalence data that they provide.

Some studies, such as by Sethi (1974) and Thacore (1975) do not show any significant correlations between gender and prevalence. Indeed, in their data presentation, they have-not disaggregated for gender, simply noting a lack ol significance between mental illness and gender. Both these studies include alcoholism. Sethi's study includes childhood disorders whereas Thacore\s study includes personality disorders, social maladjustment and suicide. The ICMR and DST sponsored (1987) study on severe mental morbidity also did not show any significant relation between prevalence of illness and gender. This study focussed only on the severe mental disorders.

Other studies, such as Shah (1980), Nandi (1975), Dube (1970), Verghese (1973), Issac and Kapur (1986), Carstairs and Kapur i 1976), Chakraborty (1990) , show that mental i l lness is more common among women. Nandi ' s study which includes eneuresis and addiction, shows no overall significant difference in prevalence of illness b e t w e e n men and w o m e n . H o w e v e r ,

disaggregated data s h o w s considerable difference in prevalence between genders with respect to both diagnostic category and age. All studies, except Issac and Kapur (1986) and Carstairs and Kapur (1976)

exclude alcohol ism and personality disorders. These latter two studies show greater female morbidity despite including alcoholism.

The factors which contributed to a lack of significance between gender and illness in some studies are the diagnostic criteria. Studies which have included personalrty disorders and alcoholism consistently show lack of significance. Studies which have included alcoholism alone have not made an overall impact on the relation between gender and illness.

Table 2 presents the disaggregated rates of prevalence of mental disorders for men and women in India. Prevalence among men is around 11 per cent and among women, about 15 per cent. This has been arrived at by averaging out the data presented in all these studies. Only those studies have been included which have presented disaggregated data on gender. All these studies give only point prevalence of illness and not rates of incidence.

Using a similar method and comparable diagnostic categories, Goldberg and Huxley (1992) compute from various community surveys in the west, that the rale of prevalence for women ts around 202 per thousand or around 20 per cent; for men, their analysis showed a rale of about 12 per cent. It is

widely noted that the prevalence rates of mental illness in the west is much higher than that in the developing countries. But higher prevalence of mental illness in women is a global phenomenon.

My inference that there are more mentally ill women than men must be further qualified. As noted earlier, most studies which show female preponderance have also excluded typically male disorders such as alcoholism, drug addiction and personality disorders. There is a debate about the inclusion of these under the category of mental illness, though all diagnostic manuals do include them. These are considered to be deviances rather than disorders. Personality disorders are argued to be not really disorders, amenable to therapeutic change but rather enduring traits or profile of a person who is socially deviant. Goldberg and Huxley (1992) while writing on the 'common mental disorders' note that they will not include personality disorders because "these are ways of describing people who differ from the majority in a stable way - except in fairly rare circumstances, one d o e s not usua l ly suddenly d e v e l o p a personal ity disorder; and, once one is present, it is unlikely to go away" (p 8). However, if one were to take the opposite view in this debate, it may turn out that inclusion of these disorders would show a different distribution of prevalence of illness in the two sexes. But this needs further corroboration through research, because, most of the studies have excluded these disorders.

2880 Economic and Political Weekly November 11, 1995

C O M M O N M E N T A L D I S O R D E R S

Next, I address the question whether women arc prone to certain types of disorders. I do this by categorising mental illnesses into the 'severe' type and the 'common' type, an established distinction in literature. Disorders such as schizophrenia, depressive psychoses, mania, epilepsy, mental retardation, and organic brain disorders arc usually treated as s evere mental d isorders . Neurot ic disorders, major depress ion, hysterias, obsessive-compulsive disorders, anxieties and phobias, somatisation disorders are classi fied as being common mental disorders. The clinical picture between these two categories of disorders varies remarkably. The degree of cognitive, personal and social impairment is very high in the ease of the severe mental disorders. In the case of the common mental disorders, even though personal distress may be very high, there is no complete cognitive breakdown. Often manifestatiot»of illness is physical, such as in hysteria and somatisation disorder. Usually social functioning is seriously impaired, and family discord and maladaptive family interactions may be common.

It is important to that calling a class of disorders as 'common mental disorders' does not necessarily imply that they are mild or that they cause very little personal su f fer ing . T h e y can c a u s e e n o r m o u s suffering, including chronicily. They often cause irreparable social alienation, loss and damage.

Some important implications fol low for the gender perspective from this distinction This distinction has profoundly influenced the mental health programme in the country, with a distinct bias of policy being in favour of the severe mental disorders. It is well known that the common mental disorders are more frequent in the community and that the percentage of population being severely i l l i sonly 1 per eent. The alleged justification is that the severely mentally ill suffer more, but this is questionable if 'suffering' is understood to include the social aspects of mental illness also. This is particularly pertinent in the case of w o m e n where p s y c h o - s o c i a l d i s t r e s s is very h i g h , sometimes high enough to lead to social isolation, violence and self-destruction. This suffering cannot be measured, evaluated nor treated with the same clinical standards of the severe mental disorders. In another paper [Davar forthcoming] 1 have argued that the national mental health policy is based on cost-effectiveness ratherthanoncommunily need in its prioritisation of the severe mental disorders. I have noted here that the policy, even though it is hailed as a landmark in the health po l i cy of the country , ignores fundamental issues in mental illness and its

treatment, such as the medicalisation of mental illness, particularly in the context of women's mental health.

Table 3 presents data collated from the different epidemiological studies on the prevalence of different mental illnesses in the male and the female populations. 1 have classed data pertinent to psychoscs, organic brain syndrome and epilepsy as belonging to the category of severe mental disorders and all neuroses as belonging to the class of the common mental disorders. I have used only those studies which have presented disaggregated data on gender and prevalence of psychotic and neurotic disorders. As is evident from the table, almost all the studies show that there is no significant difference between the two sexes on the prevalence o f the severe mental disorders. Nandi's (1975) study found no significant difference in the prevalence of psychotic depression, but found significantly greater number of women afflicted by epilepsy. But this finding is peculiar to this study and is not corroborated by other studies. Chakraborty (1990) finds greater psychotic illnesses among women. Only in the personality disorder group, male preponderance is seen. Carstairs and Kapur (1976) on the other hand note a greater prevalence of psychotic symptoms among men. However, the overall gender difference is not significant. This is true of mental retardation also , where preva lence is distributed almost equally between males and females.

But the picture changes dramatically with respect to neurosis. All studies invariably show that psychoneuroses is significantly more common among women, with most studies noting at least a 1:2 ratio in the frequency of its occurrence between males and females respectively. The overall gender based d i f ference in prevalence of the psychotic disorders is negligible, compared to the overall difference in the prevalence of the neurotic disorders. Even those studies which did not find an overall significant difference of prevalence of illness in the two sexes, such as Sethi (1974), Nandi (1975). Thacore (1975), and Sethi (1972), which found overall male preponderance of illness, note a very high frequency of occurrence of neurotic illnesses in women.

Special studies on depression give us a better idea about the prevalence of the il lness among women than that obtained from the community surveys. Sethi and Rudraprakash ( 1 9 7 9 ) found a h igher prevalence of depression among women, the frequency of occurrence being almost double that of the males in a community based sample. The greater susceptibility of women to this disorder has been recorded the world over. Singh (1968) , Ponnudurai (1981) and Bagadia (1973) all found a very

high occurrence of hysteria among women. The male- female ratio of frequency of i l lness of hysteria is 1:3. Dube (1970) too found an e x c e s s i v e representat ion ol hysteria among women. Issac and Kapur (1986) found a 1:4 ratio between men and women in the frequency of occurrence of hysteria.

Gender difference in the rates of suicides cannot be conclusively stated. Studies in Bengal (Banerjee 1990; Nandi 19791 particularly found a preponderance of woman suicides consi sternly over the last J 0 0 years. Other studies, such as by Ponnudurai and Jayakar (1980) , have also reported higher incidcnce of suicides in females. It has been noted that "female suicide due to harass-ment, dowry problems and other problems related to her family roles is high in India" [Mane 1993:137]. However, studies from other parts of the country do not show gender difference, and many of them note a male preponderance. So, as far as prevalence of suicide is concerned, no gender relvant pattern emerges from these studies.

But in terms of the profile of suicides, g e n d e r d i f f e r e n c e s may be noted . Kodandaram's (1983) study notes that more women than men complete the act of suicide In this study, it is the younger women who more often commit suicide, and among these, attempted suicides are more among the unmarried, while completed suicides were more among the married. In Kodandaram's

TABLE 2 : GENDER AND PREVALENCE OF

MENTAL. Illings

TABLE 3 ; genderwise PRF.vai.ENCE OF SEVERe

AND C O M M O N MENTAL DISORDERS

(in Rate/Thousand)

2890 Economic and Political Week ly November 11, 1995 2881

sample of women suicides, 71.23 per cent of completed suicides and 90 per cent of attempted suicides were below the age of 30 years. The highest incidence of suicides arc among housewives. Venkoba Rao (1989) had reported that of his sample of 100 cases of female burns. 70 per cent were suicidal and 74 per cent were married. Major problems reported by these women were having an alcoholic husband, wife beating, extra-marital relations and 'adjustment' problems with the husband. This study, like others, found the highest number of suicides among young, married women. It appears that financial problems, economic deprivation, and quarrel with parents lie at the root of suicides among males, whereas family discord, violence and harassment are more commonly associated with female suicides.

Recently, Agarwal (1989) in his editorial on 'Law on Bride Burning' writes, "Suicidal thoughts as well as depression are common due to adjustment problems amongst a large number of young brides. Also many psychiatric illnesses especially schizophrenia arc likely to be precipitated during early years of marriage" (p 1). Agarwal's message is that bride burning is not as important a problem as suicide among young married women and that law should focus more on the latter rather than on the former. Other than the questionable politics of the use of the dubious concept of adjustment' here, Agarwal underestimates the gravity of the problem of bride burning. His stance is provocative, especially in the context of the reality that most cases of bride burning tend to be reported as cases of depression and subsequent suicide. The simplest way of masking a case of bride burning has been to claim that the woman had 'adjustment' problems with the husband's family, was depressed and suicidal. This view has social sanction and no legal hassles are involved in reporting death due to depression and suicide. And, reporting bride burning as depression shifts culpability f rom the harassers tothe victim, for, until very recently, suicide was a punishable offence. The point is that women' s groups and other professional groups need not underestimate either the bride burning problem or the problem of suicide among young married women, as Agarwal seems to assume. Both are important requiring research, social consciousness and reform.

A neurotic disorder very common among women is somatisation disorder, where, bodily complaints such as aches and pains, headaches, dizziness, etc, have nodiscernible physical basis. This disorder must be distinguished from psycho-somatic illnesses, where, there is a physical component of the problem along with associated psychological complaints. Chadda et al (1990) found high

prevalence of this disorder among women. But his sample was hospital based, and does not probably reflect true prevalence in the communi ty . Issac and Kapur (1986), Carstairs and Kapur (1976), Chakraborty (1990), all found greater numbers of somatisers among women in their community surveys.

Table 4 shows the relative occurrence of neurotic disorders among women from data available in the different studies. Approxi-mately up to 75 per cent of a population of disturbed women will very likely be suffering from neurotic disorders. If we take it that 15 per cent of women in the community suffer from mental illnesses at any point of time, then up to 11 per cent of women in a community are likely to be suffering from the common mental disorders.

There is the doubt of ten expressed whether the reported greater prevalence of mental illness among women is not because of greater reporting of illness by women. This point of view has been put forward in the west, and it has been found that women remember their symptoms and arc more willing to acknowledge their illness, whereas men forget their symptoms [Goldberg and Huxley 1992:19]. An early review by Guttcntag et al (1980) as well as the Linderstein et al report (1993) noted that women reported more distress, but they concluded that this was because they were also more frequently ill. Studies show that there is a positive correlation between stressful life events and symptom intensity in depressed patients. Women do not necessarily experience greater life events than men and they rate stress equally objectively. There is commensurability between distress and the reported severity of symptom. This is true in the western as well as the Indian contexts, as Mahatme's (1989) study shows. The prevalence rates of hospital samples and that obtained from community surveys are approximately the same in the west. All these reflections show 'The female predominance of depression is therefore not an artefact of treatment seeking" [Linderstein et al 1993:9].

In the west, treatment seeking patterns differ markedly from that in India. All treatment settings show an overwhelming majority of women clients in the west, the ratio between men and women sometimes reaching as much as 1:3. Therefore, it was justified to wonder whether women were reporting more illness than men. But even in the west this 'reporting syndrome' among women has been questioned and seen as a typically male bias, used to undervalue women's suffering. However, in the Indian context, treatment pattern is the reverse of that obtained in the west. Women have very negligible access to mental health care and

the only setting where there is gender parity in access to health care is the community setting. In India, men are reporting more illness than women, unlike the west, so the question whether the illness rates in women is an artefact of reporting is an irrelevant one. Our Indian reality is that both men and women report less at the different psychiatric facilities, compared to the actual prevalence of mental illness in the community; and further the numberof women reporting illness at any of these facilities is much less compared to men.

P S Y C H O - S O C I A L M O D E L

I have so far made two inferences, one, that women are more frequently ill than men; and secondly, that women predominate in the common mental illness category, where as prevalence of illness is homogeneous across gender in the severe mental illness category. It is appropriate to now consider the issue of choosing the model that best explains the greater prevalence of common, specifically neurotic and depressive illnesses among women. Earlier, in the history of psychiatry, there was the belief that illnesses could be understood in biological terms. But this belief has proved to be more or less illusory. Current perspectives on mental illness prefer a bio-psycho-social model of causation of mental illness. Different types of illnesses may be conceived of as lying at different points on this multi-axial model. Different combinat ions of biological, psychological and social factors contribute towards the causation of different illnesses. To simplify matters, we might imagine mental illnesses on a straight line, with a strong biological aetiology limiting one end and a strongly psycho-social aetiology limiting the other end of the line.

It is interesting that the severe mental disorders, which show no gender difference in terms of prevalence of illness, lend themselves more towards a bio-genetic interpretation of illness, where as the common mental disorders, which are more common among women, are explained better on psycho-social terms, Disorders such as

TABLE 4 : PREVALENCE OF PSYCHOSES AND

NEUROSES AMONG WOMEN

{Percentage)

2882 Economic and Political Weekly November 11, 1995

schizophrenia, pure states of anxiety, MR, organic brain disorders, manic types of depression and some types of psychoses show s t rong ly b i o g e n e t i c modes of transmission. This is not to say that social factors are not involved at all in the course of treatment of these illnesses, but only that they are not invoked in explaining the cause of the illnesses.

Gender d i f f e rence in severe mental disorders was until recently unresearched, but recent studies show that in terms of age of onset, the role of social support, illness expression, precipitating factors and outcome of illness, there are definite gender related differences. In schizophrenia, for example, onset of illness happens earlier in men than in women [Lewis 1992; Thara and Rajkumar 1992]. Women show positive symptoms, such as depression and dysphoria, whereas men shtiw negative symptoms, such as social withdrawal, substance abuse and anti-social behaviour. Women seem to have a be t ter t r ea tmen t o u t c o m e than men . Rehospitalisation for relapse was more common among men than women, though, gender effects of readmissions became diluted after two years of follow-up. Suicide and loss of social and economic status was more common among men than women, according to Thara and Rajkumar\s study. Men of ten show more brain structural abnormalities leading to schizophrenia than women. Lewis notes, "On a range of measures there is now good evidence that antecedent deficits are more common and more severe in boys going on to develop schizophrenia than in girls" (p 446). Life events heralding onset of illness were more common among women.

However, social support and psycho-social factors do not play a major role in the aetiology of psychotic and other severe mental illnesses. Even though animal, genetic and bio-chemical studies have been carried on in the case of many forms of mental illnesses, especially schizophrenia, different forms of depression and anxiety, evidence in favour of a bio-genetic model has come only for the severe forms of mental illnesses. Goldberg and Huxley, after reviewing work in b io-genet ic s tudies in the area of depression, note "Although there is good evidence for genetic factors being important for severe forms of depression like manic-depressive illness, for the common forms of depressive illness it is difficult to show that genes have more than a non-specific effect in making disorder more likely'1 (1992:83),

Common illnesses, especially neuroses, major depression, somatisation disorders and hysterias, which are frequent among women, are better explained using a psycho-social model of mental illness. There is growing literature about the frequent recurrence of

common, especially neurotic illnesses, in fami l ies with no evidence of genet ic transmission. These illnesses are caused sometimes by a family's peculiar, often dysfunctional ways of interacting. Sharma

et a l ' s (1980) study on neurotic disorders in children noted that illness in the child, especially hysteria, which is common among women, closely resembled illness in the mother. The authors suggest that". . . family factors play an important role in the deve lopmen t of ch i ldhood n e u r o s e s " [ Sharma etal 1980:365]. Rutler( 1985)noted that family discord, especially when the hostility directly involves a child in the family, causes a range of emotional and conduct disorders in adult life. Especially in the case of neurotic depression and perpeural depress ion, common among women,the depressives consistently reported over-protective and less caring mothers, implicating the role of rigid sex-typing techniques in the aetiology of mental illness. 'Affectionlcss control ' [Parker 1983) is often cited as an important cause of the common depressive disorders. It is easy to speculate that this explanation of depressive illness is pertinent to our own culture, where rigid parenting and sex-stereotyping is the dominant model of socialisation of children [Malhoira and Malhotra 1985].

The psycho-social origins of common mental disorders, especially depression in women has been extensively studied in the west It is unfortunate that there is no available study in our own context comparable to Brown and Harris' elaborate studies on the social origins of depression (1978). It is difficult to review this entire literature within the scope of this paper and indeed , unnecessary to do so. The upshot of the discussion so far is simply that women seem to be more prone to those disorders which have a psycho*social origin rather than a bio-genetic origin. It is telling that where aetiology is strongly bio-genetic, no gender difference is seen in the prevalence of illness; whereas, those disorders with a strong psycho-social origin show a gross difference. T h e r e f o r e , gender d i f f e r e n c e in the prevalenceof mental illness is to be explained

psycho-socially rather than bio-genetically. A purely bio-genetic model of explanation of mental illness in women will beinadequate, as it will altogether ignore the issues related to the social status of women, the psycho-social stressors associated with their status, the social effects of their illness in their relationships, and a vast number of other important issues which are of equal social c o n s e q u e n c e as they are of c l in ica l consequence.

Table 5 shows the total psychiatric disturbance of women grouped according to their developmental stages: childhood (up to 14 years); reproductive years (between 14-40 years); menopausal (between 40-49 years);and finally,old agc(beyond 50years). It must be cautioned that this grouping is a re-classified, qualitative one and does not conform to the age wise grouping of data in the primary studies. This re-grouping of data had to be adopted because the studies did not all always conform to a standard age-grouping. Also, this qualitative re-grouping threw up some telling patterns of occurrence of illness, in terms of developmental stages of a woman's life. This approach also made it possible to expose certain pseudo-e x p l a n a t i o n s c o m m o n l y o f fered by professionals for the greater prevalence of mental disorders among women, notably, 'the menopausal theory of mental illness', which I shall attend to below. It seemed more significant therefore to re-group the data qualitatively rather than retain the original quantitative grouping.

It was sometimes difficult to fit the agewise grouping of data from the primary studies into this qualitative grouping. I have had to make some intuitive choices about the inclusion of certain age groups in the studies under particular developmental descriptors. Thus, for example, in Nandi's (1975) study, women between 12 and 14 years have a lso been included in the 'reproductive years*, as these years fal I withi n the age class 12-35 of his study. In the same study, the 36-47 class has been included in the 'menopausal years', even though the years 36-40 would still be reproductive from the qualitative classification.

TABLE 5 : A G E AND P R E V A L E N T OF M E N T A L ILLNESS IN Women

2890 Economic and Political Weekly November 11, 1995 2883

From the table, it is evident that the prevalence or mental illness is phenomenally high during the reproductive years. The menopausal years and beyond 5 0 years do not show very high prevalence in comparison to the reproductive years. Prevalence of menial illness in women increases to steep levels after childhood until the age of about 40 and falls off steeply duri ng the menopausal years and later. This trend is consistent in all the studies noted, and especially so for the common mental disorders. The difference in age wise occurrence of illness is not so graphic in the case of prevalence of all disorders as it is in the case of neurotic disorders, as is evident from the data presented by Dube (1970) and Chakraborty (1990) on neuroses, and Ponnudurai (1973) on hysteria.

Dube's sample of women showed that 79.2 per cent of neurotic illness occurred in the 15-34 age group. Chakraborty's sample showed that 53.6 per ccnt of mental illness occurred in the 14-39 age group. In Ponnudurai's sample 80.4 percent of hysteria

belong it to the 16-35 age group. Suicides are also highest in the 21-40 age group. Kodandaram s (1983) study on suicide could not be appropriately represented in the table, because the lowest age-class in his study was below 20', and hence this had to be included

in the childhood group. Therefore, in this study, only 52 per cent of total suicides and 54 percent of completed suicides fall between the 21-40 years group, which is in itself high enough. But 1 suspect that some cases which could have been legitimately included in the class of reproductive years has now been lost to this group and has gone under the childhood group. This explains the tact that the 'childhood' group in Kodandaram's study shows 35 per cent of total suicides and 31 per cent of completed suicides. This gives us a distorted picture of high rates of suicides among girl children.

T h o u g h V e r g h e s e ( 1 9 7 3 ) found no overall difference in the prevalence of illness between the two genders, he did f ind a s ign i f i cant age -re la ted gender difference. He writes, "Our study show that women are more prone to get psychia-tric disturbance both psychoneurotic and nonpsychoneurotic during the 31 -45 years period" (p 616). Nandi (1975) notes, "... males and females, according to their age-groups, show remarkable difference in their rate of morbidity. Females show a galloping rise in their rate of morbidity till the age of 36-47 years and then it drops appreciably in the higher age-groups. But males show a gradual rise in the rate of morbidity with a slight drop in the 24-35 years age group till the age of 36-47 years and then it sharply shoots up in the higher age-groups" tp 05).

In explaining the greater prevalence of mental illness in women, Verghese (1973) writes. 'This vulnerability of women to have psychiatric disturbance is difllcult to explain. The social stresses of women and the factors a s s o c i a t e d wi th the m e n o p a u s e may contribute to this vulnerability1' (p 616). Shah el al (1980) notes that the greater prevalence of mental illness "is positively l inked with universa l p h e n o m e n a of physiological and psychological changes occurring in females after menopause , making them more vulnerable..." (p 387).

The connection posed between menopause and greater mental illness in women needs to be thoroughly questioned. That this view is permeated by myths is documented in recent reviews of literature (Mathews 1992). The Linderstein et al (1993) review also s h o w e d that any increase in rates of depression in menopausal women is not explained by hormonal changes occurring at menopause. Mid-life changes, such as physical problems, loss of spouse, change in career options, and other psycho-social stressors are related to illness rather than menopause per set though hysterectomies and other g y n a e c o l o g i c a l p r o b l e m s associated with menopause might create distress. From ourown data, it is very evident that morbidity rates in women fall off after 4 0 years or so, thereby throwing serious doubt on the 'menopausal' theory of mental illness in women.

Causal attributions of mental illness to women's progenitive capacity is not a new phenomenon. There was a time in America as recent as the 1870s when insanity was commonly 'cured' by performing bilateral ovariectomies (Grob 1983; 122-23]. To grasp at cliched and socio-culturally metaphorised pseudo-explanations is to be relieved of a deeper commitment to scientific objectivity and to social change. Once it is stated with professional authority that women's mental

illness is caused by her sex hormones, further critical inquiry is rendered unnecessary. This casualness, this strange urge to link all disorders to woman's reproductive system that is so prevalent in health studies reflects only the unconscious fear that the system, with its present male-contracted power e q u a t i o n s , might c h a n g e wi th n e w knowledge.

Table 6 shows the variance ol mental illness with respect to marital status. Carstairs and Kapur's (1976) study at Kota did not find any significant relation between marital status and case rate. Nandi (1975), Sclht (1972, 1974) and Thacore (1975) have not presented disaggregated data on gender and marital status. In these studies, except Sethi (1972), it is evident that in general, being married is more stressful than being single. Sethi (1972) shows a greater frequency of illness in the 'single' category only because 67 per ccnt of the disturbed population belong to the 0 -10 years age-group and MR was over-represented in the sample. All these studies, except Sethi (1972) also show that being widowed, separated or divorced is the most vulnerable group for mental illness.

All other studies (Dube 1970; Verghese 1973; Chakraborty 1990) consistently show higher frequency of illness in married women as compared to married men, and greater frequency of illness in single women as compared to single men. That is, in all categories related to marital status, women are more stressed than men. Married women are more prone to illness than single women, though di voreed/separated/widowed women show the highest frequency of illness. In the west, contrary to our o w n experience, divorced and widowed women show lower rates of mental illness than married women, on par with single women. No conclusions may be drawn about the frequency of illness in men with respect to their marital status from these studies alone, though divorcees

TABLE 6 ; M E N T A L ILLNLSS, MARITAL STATUS AND GENDER

2890 Economic and Political Weekly November 11, 1995