Persons with Disabilities

The National Disability Survey in Afghanistan provides a wealth of information that will enrich the understanding of the needs of disabled persons. As professionals working in the mental health field we are pleased that the NDSA has included mental health aspects in its survey. This is important since mental disorders are still a neglected health priority, though the evidence of their importance on well-being is increasing. The groundbreaking WHO/World Bank Report on the Global Burden of Disease (Murray and Lopez 1996) calculated that of five of the ten leading causes of disability worldwidemeasured in ‘years lived with disability’ were psychiatric conditions. Disability related to mental disorders is expected rise, in both the developed as well as the developing world. A recent study estimates that in low-income countries unipolar depression will be the third leading cause of disability in 2030, after HIV-AIDS and perinatal conditions, but before malaria, tuberculosis, diarrheal diseases and lower respiratory infections. (Mathers & Loncar 2006).

disable1In its definition of disability the NSDA concentrates on more severe mental disabilities such as severev learning disabilities and psychotic disorders. The identification of mentally disabled persons was done through screening questions asked to the head of the household. The section on mental health problems comprised of eight questions that focused on psychotic symptoms such as delusions (‘Does any member of your family constantly make up imaginary stories, which are not true?), hallucinations (“Does any member of your family see or hear things that are not there?”), disorganized speech (“Does any member of your family talk to him/herself constantly?”) and severe behavioral disturbances such as aggression and selfmutilation. These screening questions will most probably identify persons with severe mental disorders such as schizophrenia, bipolar disorder or psychotic depression. It is less likely that all mental disorders will be identified. In particular, many people suffering from ‘common mental disorders’ such as depression, anxiety disorders and post-traumatic stress disorders are probably not identified by the screener. It is important to realize this because the implication is that the figures about ‘mental disability’ cannot be regarded as prevalence figures for mental disorders in Afghanistan. Indeed, compared with the NDSA, studies identifying the symptoms of common mental disorders (Cardozo et al 2004, Scholte et al 2004) find much higher prevalence of such symptoms of common mental disorder in the population than the rates of mental disabilities in the NDSA.

This fact is acknowledged by the authors of the report. In fact they discuss the issue in section 3 of the report, which looks at ‘well-being in general’. When they use less stringent criteria and include a variety of physical and mental difficulties in the analysis the prevalence of persons with disabilities rises to 36.8%.

As mental health professionals we are particularly struck by the high levels of mental distress reported by persons with disability. These persons suffer tremendously and the robust findings underscore the importance of inclusion of mental health and psychosocial components in disability programs.

Another striking result is the finding that 0.56% of the population suffers from epilepsy. While this figure is based on self reporting it does confirm other studies in the region such as in rural Pakistan were high prevalence figures for epilepsy were found (Aziz et al. 1994). The public health implications are significant: Epilepsy fulfils the criteria for a public health priority: it is a chronic condition that is severely disabling and can be very effectively treated against low costs. The implications of the NSDA are that due attention should be given to disability and mental health (including chronic mental disorders and epilepsy). It underlines that the step of the Afghan Government to include mental health and disability in the Basic Package of Health Services was fully justified. The challenge for both policy makers and health care providers is to develop effective ways to implement mental health and psychosocial services in the intervention package. These interventions could include 1) training of health professionals to identify the mental problems in disabled persons, 2) increase the availability of biopsychosocial treatment of those individuals who have developed identifiable mental disorders and 3) to encourage persons with similar problems cope better with the limitations due to their disabilities (for example through psychosocial interventions such as counselling and support groups).