Poverty and mental illness interact in a negative cycle that places people living in poverty at greater risk of developing mental disorders, while people living with mental disorders are at greater risk of sliding into poverty.

Poverty and female gender have been statistically associated with depression and anxiety in developed countries. In low and middle-income countries, women consistently present with higher rates of anxiety and depression.

• loss of employment
• social drift
• housing problems
• social exclusion
• high and numerous stressors
• reduced access to social capital/safety net
• malnutrition
• obstetric risks
• violence and trauma

Local studies show that women experiencing psychological distress regularly cite a lack of social support. PMHP’s data confirms this, showing  that of all women attending the Project’s counselling service

A lack of social support can cause lonliness, emotional isolation and profound feelings of distress.

Research shows that these feelings can prevent women from receiving the help they need during pregnancy.

A lack of partner support has been found to be an important risk factor for mental illness during pregnancy.

In developed countries, 26% of teen mothers develop postnatal depression.

It is speculated that the rate could be twice as high in South Africa, where 1/6 of teen pregnancies are among black African girls.

Adolescence is a significant risk factor for mental illness, with mental illness being associated with high rates of maternal mortality in this age group, often due to suicide.

Cognitive developmental changes and trauma are complicating factors in adolescent mental illness requiring special mental health care.

Almost half (43.7%) of all people living with HIV/AIDS in South Africa have a diagnosable mental illness. This is significantly higher than the national prevalence of 30.3% for any mental health disorder (Freeman et al, 2008; Herman et al, 2009).

HIV infection may predispose patients to mental distress and vice versa (Ciesla & Roberts, 2001).

HIV-positive pregnant women are more likely to have poorer mental health as pregnant women who were HIV-negative (Bernatsky et al, 2007).

Mental illness impacts negatively on AIDS treatment and uptake of antenatal care while being a significant factor in AIDS-related mortality among women (Stein & Rochat, 2006).

HIV is a proven risk factor for both violence against women and mental distress, while mental distress is a risk factor for HIV infection and often a consequence of violence. Read the PMHP brief on HIV and mental illness.

Violence is a significant factor in burden of disease. Women are disproportionately affected by violence. They experience a high degree of trauma, which places them at a significantly higher risk of mental illness than men.

South Africa has an extraodrinary high level of violence, where women experience violence socially, in interpersonal settings such as domestic abuse, and increasingly, from health workers in an over-burdened health system.

A large 2009 study by Jewkes found that 28% of men between 18 and 49 have perpetrated rape, almost half of whom report having done so more than once. Almost half of all men in the study report being physically violent with an intimate partner.

This concurs with Dunkle’s 2003 Soweto study, where 56% of pregnant women were found to have experienced violence from an intimate partner. A 2003 study in Durban found 34% of pregnant women had experienced partner abuse during their pregnancy (Mbokota, 2003). Violence in personal relationships is likely to increase as the pregnancy progresses.

Women who are displaced due to conflict or economic reasons experience considerable trauma.

They are particularly vulnerable to violence, the impacts of poverty and inferior health care.

Violent conflict, loss of loved ones, torture, rape and dispossession are just some of the traumatic experiences which can significantly affect a woman's mental health.

Separation from families, partners or other familiar and supportive structures can cause considerable distress. Social isolation or exclusion, discrimination and xenophobia in the countries in which they find themselves can further exacerbate existing traumas and mental anguish.

Refugee women are therefore at increased risk of mental illness and require additional mental health support, including the need for multilingual or translation services. Read the PMHP brief on refugee and maternal mental illness.

Mental illness is linked with substance abuse, while substance abuse contributes to onset of mental illness. A study at one Cape Town hospital found that 10% of pregnant women were using 'tik' (methamphetamine).

Alcohol, crack/cocaine, heroin and methamphetamine are the most abused substances in South Africa, with alcohol abuse being the most significant problem.

The South African Community Epidemiology Network on Drug Use (SACENDU) indicates that substance abuse is on the increase in South Africa. More and more people are seeking treatment and mortality rates linked to substance abuse are soaring.

Findings show that the average age of those seeking treatment is getting younger.

The following questions could be useful in determining a woman's risk for mental illness.

Does the woman have conflictual relationships, either with her mother, wider family or community?

Is the pregnancy unwanted or unplanned?

Does the woman have a history of mental illness? Take particular note of

• postnatal depression (PND) after a previous pregnancy - there is a 10-35% chance of PND occurring again
• bipolar affective disorder (also known as 'manic depression') - this condition can increase a woman's chance of PND by 25%
• previous anxiety or depression during a previous pregnancy has high chance of occuring again.

Could she have experienced traumas which have not been resolved, for example, traumas related to

• pregnancy or childbirth (miscarriage, termination of pregnancy, death of a baby, previous difficult pregnancy and delivery)
• crime, violence, war or torture (especially among refugee women)
• interpersonal or conflictual relationships

Has the women recently experienced a major life event, such as

• loss of employment
• death of a loved one
• divorce
• moving home

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