The Demography of Mental Health Among Mature Adults in a Low-Income, High-HIV-Prevalence Context

Abstract

Very few studies have investigated mental health in sub-Saharan Africa (SSA). Using data from Malawi, this article provides a first picture of the demography of depression and anxiety (DA) among mature adults (aged 45 or older) in a low-income country with high HIV prevalence. DA are more frequent among women than men, and individuals affected by one are often affected by the other. DA are associated with adverse outcomes, such as poorer nutrition intake and reduced work efforts. DA also increase substantially with age, and mature adults can expect to spend a substantial fraction of their remaining lifetime-for instance, 52 % for a 55-year-old woman-affected by DA. The positive age gradients of DA are not due to cohort effects, and they are in sharp contrast to the age pattern of mental health that has been shown in high-income contexts, where older individuals often experience lower levels of DA. Although socioeconomic and risk- or uncertainty-related stressors are strongly associated with DA, they do not explain the positive age gradients and gender gap in DA. Stressors related to physical health, however, do. Hence, our analyses suggest that the general decline of physical health with age is the key driver of the rise of DA with age in this low-income SSA context.

Keywords: Aging; Anxiety; Depression; Malawi; Mental health.

Fig. 1

Gains person years lived by age group 2010–2060 (Malawi) and survival probability from age 35 to 65 1970–2020 (Malawi). Panel a is based on Arriaga (1984) decomposition of changes life expectancy at age 25 (e₂₅) during 2010–2060. Gains in e₂₅ during 2010–2060 are distributed as follows: 4.1 additional years, or 38 % of the overall adult life expectancy gain, will occur among individuals aged 45–64; and 5.1 years, or 47 % of the adult life expectancy gain, will occur among individuals aged 65+. The recent and projected future gains in adult survival in panels a and b are importantly driven by the continued roll-out of antiretroviral treatment (ART) that has reduced the mortality and morbidity consequences of HIV infection (Bor et al. 2013; Floyd et al. 2012), reductions in malaria infections and improved treatment of malaria (WHO 2010), and gains in the treatment of selected noncommunicable diseases (NCDs) (Msyamboza et al. 2011; Ntsekhe and Damasceno 2013). Source: Based on UN Word Population Prospects (United Nations Population Division 2012) period life tables

Fig. 2

Age patterns of depression, anxiety, and overall mental health for mature adults age 45 or older in 2012–2013, Malawi. Marginal means (with 95 % confidence intervals) obtained by regressing the respective mental health score on a cubic function of age, separately by sex. Analyses are pooled across 2012 and 2013 MLSFH mature adult survey. Confidence intervals are adjusted for clustering within respondents. Analyses control for schooling, region, and MLSFH wave. Religion is not controlled for because it is essentially collinear with region in the MLSFH; marital status is not controlled for because it is time-variant and endogenous with respect to mental health. Estimated linear approximations of these age patterns along with tests for gender differences are reported in Online Resource 1, Table S10

Fig. 3

Distribution of remaining life expectancy by mental health: no anxiety/depression (No AD), mild anxiety/depression (Mild AD), moderate or severe anxiety/depression (Mod/Sev AD). The figure shows the proportion of remaining life an average individual will spend with no, mild, or moderately severe anxiety/depression at age 45, 55, 65, and 75. Top panel is for females; bottom panel is for males. The height and area of each bar is proportional to the overall remaining life expectancy of the synthetic cohorts with initial ages of 45, 55, 65, and 75 years; and the differently shaded areas represent the distribution of the remaining life expectancy across the three mental health states: no anxiety/depression (No AD), mild anxiety/depression (Mild AD), moderately or severe anxiety/depression (Moderate/Severe AD). The bars do not necessarily reflect the ordering of these life-years by disability states because individuals in our analysis can recover and relapse between disability states, so not all years of limitation are spent at the end of life