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# Prevalence of Mental Disorders in Martinique, French West Indies: A Community-based Epidemiological Study

J Lacoste, S Merle, N Ballon, A Charles-Nicolas, G Ursulet, A Messiah

► To cite this version:

J Lacoste, S Merle, N Ballon, A Charles-Nicolas, G Ursulet, et al.. Prevalence of Mental Disorders in Martinique, French West Indies: A Community-based Epidemiological Study. West Indian Medical Journal, 2018, 67 (4), pp.317-322. 10.7727/wimj.2016.216 . inserm-04022479

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# Prevalence of Mental Disorders in Martinique, French West Indies:
A Community-based Epidemiological Study

J Lacoste¹,³, S Merle², N Ballon¹,⁴, A Charles-Nicolas¹, G Ursulet¹, A Messiah³

## ABSTRACT

**Objective:** This study aimed to estimate the prevalence of mental disorders in the population of Martinique, as part of the survey entitled 'Mental Health in the General Population – Images and Realities' (Santé Mentale en Population Générale – Images et Réalités). The survey was a multicentre epidemiological study in the general population, conducted in mainland France and French overseas islands between 1997 and 2006, under the authority of the World Health Organization Collaborating Centre for Training and Research in Mental Health (Lille, France).

**Methods:** The study took place in 2000. Participants aged 18 years or over were recruited in public places, using the quota sampling method, and interviewed using the Mini International Neuropsychiatric Interview.

**Results:** A total of 900 participants (52.7% women) with a mean age of 43 years completed the survey. Lifetime prevalence of any mental disorder was 29%. Mood (15%) and anxiety disorders (17%) were the most frequent. The rate of suicide attempts was low (4.2% lifetime), while the frequency of suicidal thoughts was high (11% past month) and similar to the frequency in mainland France.

**Conclusion:** Mental disorders, especially mood and anxiety disorders, were as frequent in Martinique as in mainland France. The lower rates of suicide attempts, in spite of high rates of suicidal thoughts, might deserve further investigation. Our results should strengthen the development of a system of diagnosis and care for these disorders, especially to prevent suicidal behaviours and reduce morbidity and mortality.

**Keywords:** Epidemiology, health survey, Martinique, mental disorders, prevalence

# Prevalencia de los trastornos mentales en Martinica, Antillas Francesas:
un estudio epidemiológico comunitario

J Lacoste¹,³, S Merle², N Ballon¹,⁴, A Charles-Nicolas¹, G Ursulet¹, A Messiah³

## RESUMEN

**Objetivo:** Este estudio tuvo por objeto estimar la prevalencia de los trastornos mentales en la población de Martinica, como parte de la encuesta intitulada 'Salud Mental en la Población General – Imágenes y Realidades' (Santé mentale at Population Générale – Images et Réalités).

<footnote>From: ¹CHU de Martinique, Department of Psychiatry and Addictology, CHU Martinique University Hospital, Fort-de-France, Martinique, French West Indies, ²Regional Health Observatory, Fort-de-France, Martinique, French West Indies, ³CESP/Inserm U1018-Team IPSOM, Paris, France and ⁴UMR 1253, iBrain, Université de Tours, Inserm & CHRU Tours, France.</footnote>

<footnote>Correspondence: Dr J Lacoste, Service de Psychiatrie et Addictologie, Hôpital Pierre Zobda Quitman, CHU de Martinique, CS 90632, F-97261 Fort de France cedex, Martinique, French West Indies. Email: jerome.lacoste@chu-martinique.fr</footnote>
La encuesta fue un estudio epidemiológico multicéntrico en la población general, realizado en Francia continental y en las islas francesas de ultramar entre 1997 y 2006, bajo la autoridad del Centro de Colaboración de la Organización Mundial de la Salud para la Formación y la Investigación de la Salud Mental (Lille, Francia).

**Métodos:** El estudio tuvo lugar en el año 2000. Los participantes mayores de 18 años fueron reclutados en lugares públicos, utilizando el método de muestreo por cuotas, y entrevistados usando la Mini Entrevista Neuropsiquiátrica Internacional.

**Resultados:** Un total de 900 participantes (52.7% mujeres) con edad promedio de 43 años completó la encuesta. La prevalencia de por vida de cualquier trastorno mental fue de 29%. Los estados de ánimo (15%) y los trastornos de ansiedad (17%) fueron los más frecuentes. La tasa de intentos de suicidio fue baja (4.2% por tiempo de vida), mientras que la frecuencia de los pensamientos suicidas fue alta (11% el mes pasado) y similar a la frecuencia en la Francia continental.

**Conclusión:** Los trastornos mentales, especialmente los estados de ánimo y los trastornos de ansiedad, eran tan frecuentes en Martinica como en la Francia continental. Las tasas más bajas de intentos de suicidio, a pesar de los altos índices de pensamientos suicidas, podrían merecer investigación adicional. Nuestros resultados deben fortalecer el desarrollo de un sistema de diagnóstico y cuidado para estos trastornos, especialmente para prevenir comportamientos suicidas y reducir la morbilidad y la mortalidad.

**Palabras clave:** Epidemiología, encuesta de salud, Martinica, trastornos mentales, prevalencia

West Indian Med J 2018; 67 (4): 318

## INTRODUCTION

Mental disorders are a public health problem worldwide. Both at the national and local levels, the development of care and prevention programmes adapted to the needs of the population have to lean on epidemiological data. Prevalence of mental disorders in the general population has been assessed in several countries (1), notably in the United States of America (2–4), Europe (5–7) and Australia (8). However, in the Caribbean, there is a paucity of recent literature on the prevalence of mental disorders (9), with a major focus on psychotic disorders in Afro-Caribbean immigrants in European countries (10).

In France, the survey 'Mental Health in the General Population – Images and Realities' (Santé Mentale en Population Générale – Images et Réalités; SMPG) was conducted between 1997 and 2006, by the Northern French Psychiatric Epidemiology Association (Association Septentrionale d'Epidemiologie Psychiatrique) and the World Health Organization Collaborating Centre for Training and Research in Mental Health, Lille, France (WHO-CC), in collaboration with the French Ministry of Health (11). Participants were recruited in 71 centres in mainland and overseas France. For each centre, around 900 subjects were recruited in public places,

using the quota sampling method. Martinique was one of the centres; its survey was carried out in 2000.

With an area of 1100 km², Martinique is a French overseas island with a population of 385 500 in 2013 (12), the majority of whom being Afro-Caribbean (fluent in both French and Creole). Since 1950, Martinique has experienced a major transition socially and economically, with a rapidly growing economy, a significant increase in *per capita* gross domestic product, and dramatic social and psychological changes, evolving within two generations from a rural to the current industrialized society (13). Based on the same healthcare system as other regions in mainland France, the actors of the Martinique's mental health system have nevertheless to deal with the consequences of the rapid evolution in Martinique's society (13).

As part of the SMPG survey, the aim of this study was to measure the prevalence of the most frequent mental disorders in a sample representative of the general population of Martinique, in order to design mental healthcare programmes adapted to the local reality.

## SUBJECTS AND METHODS

The method of the SMPG survey has been described in detail elsewhere (14). The study protocol and
questionnaires were reviewed and approved by a nation-
al ethics committee.

Non-institutionalized and non-homeless subjects
aged 18 years or over were recruited in public places
in 2000. Subjects were selected by quota sampling
stratified by age, gender, educational and occupational
levels, socio-economic status and place of residence; the
Martinique population structure was given by the 1999
national census (15).

After written consent was obtained, a 50-item struc-
tured questionnaire was administered face-to-face.
Interviewers (nurses, nursing students and social work-
ers) received a special three-day training course by
WHO-CC experts. An expert team created a French-
Creole translation using the double translation approach.
However, Creole was rarely used (0.2%) because most
participants spoke French. Each interviewer was super-
vised to ensure that questions were asked correctly and
data were properly collected.

Sociodemographic data included gender, age, marital status, educational level, employment, monthly family income, household size, and religion.

The World Health Organization's ICD-10 diagnosis of mental disorders was assessed using the Mini International Neuropsychiatric Interview (MINI) (16).

Disorders included:

* mood disorders: major depressive disorder (MDD) – single (F32), MDD – recurrent (F33), dysthymia (F34), current mania (F30) and lifetime mania (F31);

* anxiety disorders: time frame:

* one month: panic disorder (F41.0), agoraphobia (F40.0), social anxiety (F40.1), obsessive compulsive disorder (F42), post-traumatic stress disorder (F43.1); and

* six months: generalized anxiety disorder (F41.1);

* psychotic syndrome (lifetime);

* current bulimia and anorexia (three months); and

* substance-use disorders (12 months).

Suicidal behaviours were assessed using the MINI
criteria, which explore thoughts or wishes related to
death and suicidal ideations, and suicide attempts. This
assessment yielded three risk categories: low, medium
and high.

**Statistical analyses**

Statistical analyses were done with Epi-Info, version
6 (CDC Atlanta, 1994). We first performed univariate

analysis of sociodemographic characteristics. Then, psy-
chiatric diagnoses were analysed by sociodemographic
variables, using analysis of variance and t-test for quan-
titative data, and Chi-square and Fisher's exact test for
categorical data. Significance level was set at 0.05.

RESULTS

A total of 900 participants (426 men and 474 women) completed the survey, 92% of whom were from Martinique, 1% from Guadeloupe, 5% from mainland France and 2% from various foreign countries (mainly Dominica, Saint Lucia and Haiti). The mean age was 43 years (standard deviation = 17 years; range = 18–91 years).

As for education, 22% had a primary school level
(one to five years) and 23% a university level (more than
12 years).

Sixty-six per cent of households consisted of fewer
than four persons, and 49% earned less than 1300€
per month. Of those, 8% had less than 533€ per month
(Table 1).

At least one mental disorder was diagnosed in 29%
of the participants.

Participants with at least one mental disorder, com-
pared with those without any mental disorder, were more
likely to be women, unemployed and single/widowed/
divorced. The two most frequent disorders were mood
disorders and anxiety disorders, affecting 15% and 17%
of the participants, respectively (Table 2).

Prevalence of suicidal risk (defined as having had suci-
cidal thoughts in the month before the assessment) was
11% and was more in women than men. Of these, 62%
were at low suicidal risk ('wish to be dead' or 'desire
to hurt oneself in the past month' or 'lifetime suicide
attempt'), 15% at medium suicidal risk ('suicide ideas
in the past month' or 'desire to hurt oneself in the past
month' and 'lifetime suicide attempt'), and 23% at high
suicidal risk ('having established a way to commit sui-
cide' or 'suicide attempt in the past month' or 'suicide
ideas in the past month' and 'lifetime suicide attempt').
Compared with low suicidal risk, higher suicidal risk
(both medium and high categories) was strongly associ-
ated with MDD – single episode (odds ratio (OR): 9.5;
95% confidence interval (CI): 4.0, 22.6) and dysthy-
mia (OR: 3.5; 95% CI: 0.6, 20.2), but not with MDD
– recurrent (OR: 0.53; 95% CI: 0.17, 1.6) or any anxiety
disorder (OR: 0.23; 95% CI: 0.36, 1.5).

Alcohol-use disorder affected 3% of the study popu-
lation (2% abuse and 1% dependence) and were more
frequent among men than women. Cannabis users were
4.5%. Substances-use disorder affected 1.7% of the study population (0.9% abuse and 0.8% dependence) and were more frequent among male, young, single and unemployed participants.

No diagnosis of current anorexia was made; current bulimia nervosa affected 1% of the participants, but only women aged between 18 and 49 years.

## DISCUSSION

This study was the first exploring the prevalence of mental disorders conducted in a community sample in Martinique. As a part of the SMPG surveys, three other

<table><caption>Table 1: Characteristics of the study population</caption><thead><tr><th></th><th>n</th><th>%</th></tr></thead><tbody><tr><td>Gender (n = 900)</td><td></td><td></td></tr><tr><td>Male</td><td>426</td><td>47.3</td></tr><tr><td>Female</td><td>474</td><td>52.7</td></tr><tr><td>Age (years) (n = 900)</td><td></td><td></td></tr><tr><td>18-29</td><td>239</td><td>26.6</td></tr><tr><td>30-39</td><td>208</td><td>23.1</td></tr><tr><td>40-49</td><td>163</td><td>18.1</td></tr><tr><td>50-59</td><td>118</td><td>13.1</td></tr><tr><td>60-74</td><td>172</td><td>19.1</td></tr><tr><td>Marital status (n = 899)</td><td></td><td></td></tr><tr><td>Single</td><td>360</td><td>40.0</td></tr><tr><td>Married</td><td>431</td><td>47.9</td></tr><tr><td>Divorced/separated</td><td>58</td><td>6.5</td></tr><tr><td>Widowed</td><td>50</td><td>5.6</td></tr><tr><td>Educational level (n = 882)</td><td></td><td></td></tr><tr><td>Illiterate</td><td>13</td><td>1.5</td></tr><tr><td>Primary school</td><td>181</td><td>20.5</td></tr><tr><td>Secondary school</td><td>278</td><td>31.5</td></tr><tr><td>Baccalaureate or university level</td><td>410</td><td>46.5</td></tr><tr><td>Employment (n = 900)</td><td></td><td></td></tr><tr><td>Employed</td><td>503</td><td>55.9</td></tr><tr><td>Retired</td><td>147</td><td>16.3</td></tr><tr><td>Unemployed</td><td>97</td><td>10.8</td></tr><tr><td>Students</td><td>85</td><td>9.4</td></tr><tr><td>Others</td><td>68</td><td>7.6</td></tr><tr><td>Monthly family income (€) (n = 845)</td><td></td><td></td></tr><tr><td>Less than 534</td><td>67</td><td>7.9</td></tr><tr><td>534-838</td><td>139</td><td>16.5</td></tr><tr><td>839-1295</td><td>212</td><td>25.1</td></tr><tr><td>1296-2515</td><td>270</td><td>31.9</td></tr><tr><td>2515-6402</td><td>144</td><td>17.0</td></tr><tr><td>6403 or more</td><td>13</td><td>1.6</td></tr><tr><td>Persons in family (n = 889)</td><td></td><td></td></tr><tr><td>Single</td><td>141</td><td>15.9</td></tr><tr><td>Couple</td><td>202</td><td>22.7</td></tr><tr><td>3-4</td><td>389</td><td>43.7</td></tr><tr><td>5-6</td><td>126</td><td>14.2</td></tr><tr><td>7-8</td><td>24</td><td>2.7</td></tr><tr><td>9 or more</td><td>7</td><td>0.8</td></tr></tbody></table>

French overseas islands had used the same study protocol: Guadeloupe, Reunion Island and New Caledonia. Results of these surveys have been published elsewhere (17-19).

In our study, at least one mental disorder was diagnosed in 29% of the study population. Our results were similar with those in mainland France (31%), Guadeloupe (32%) and Reunion Island (30%), but lower than those in New Caledonia (46%) (17-20). Mood and anxiety disorders were the most common disorders in our study, as well as in the other overseas territories.

Prevalence of psychotic syndrome (3.3%) was in line with the rate in mainland France (2.8%; n = 36 000) (20). In a previous paper, Ballon *et al* compared the prevalence of psychosis in Martinique and Guadeloupe combined to partial data from the first seven French sites (n = 5502), and found a significant discrepancy between mainland France (1.8%) and French West Indies (4.4%) (*p* < 0.0001) (21). Therefore, it can be said that the difference between the two islands and mainland France (4.4% versus 2.8%) remains statistically significant (*p* < 0.0001) even when considering the larger number of French sites (44 sites; n = 36 000) (20).

In our study, 4.2% of the participants had a lifetime prevalence of at least one suicide attempt, while data from the national survey found a lifetime prevalence of 7.8% (22). Even though lifetime prevalence of suicide attempts was lower in Martinique than in mainland France, suicidal risk rates were quite similar, with 11% in Martinique and 13.7% in mainland France. Our results may be due to an under-reporting of suicide attempts in this population, with non-acceptance or tendency to trivialization and minimization of such behaviour in the West Indian society, particularly for cultural and religious reasons, more so than in mainland France.

## Limitations

Firstly, due to inclusion criteria, several important population segments were not represented, such as those in institutions, in hospitals, the homeless and prison inmates. Thus, the prevalence estimate of mental disorders may have been under-estimated. In addition, as in other SMPG studies, patients with mental illness might be more reluctant than others to participate in the survey.

Although the WHO-CC supported the selection of the MINI (16), such instrument had not been validated in the French West Indies. However, the use of the same instrument in all surveys conducted in France allowed
<table><caption>Table 2: Prevalence of mental disorders by Mini International Neuropsychiatric Interview, according to sociodemographic characteristics (% in subpopulation)</caption><thead><tr><th></th><th>At least one mental disorder (n = 260)</th><th>At least one mood disorder (n = 135)</th><th>Major depressive disorder - single (n = 119)</th><th>Major depressive disorder - recurrent (n = 58)</th><th>At least one anxiety disorder (n = 155)</th><th>Suicidal risk (n = 99)</th><th>Suicide attempt (n = 37)</th><th>Psychotic syndrome (n = 30)</th><th>Alcohol-use disorder (n = 27)</th><th>Substance-use disorder (n = 15)</th></tr></thead><tbody><tr><td>Total (n = 900)</td><td>29.2</td><td>15.0</td><td>13.2</td><td>6.4</td><td>17.2</td><td>11.0</td><td>4.2</td><td>3.3</td><td>3.0</td><td>1.7</td></tr><tr><td>Gender (p)</td><td>0.001</td><td>0.0006</td><td>0.0003</td><td>0.004</td><td>0.001</td><td>0.04</td><td>NS</td><td>NS</td><td>0.005</td><td>0.0001</td></tr><tr><td>Men (n = 426)</td><td>23.9</td><td>10.8</td><td>8.9</td><td>4.0</td><td>15.5</td><td>8.2</td><td>3.3</td><td>2.3</td><td>4.7</td><td>3.5</td></tr><tr><td>Women (n = 474)</td><td>33.9</td><td>18.8</td><td>17.1</td><td>8.7</td><td>22.0</td><td>13.5</td><td>4.9</td><td>4.2</td><td>1.5</td><td>0.0</td></tr><tr><td>Age (p)</td><td>NS</td><td>NS</td><td>NS</td><td>NS</td><td>NS</td><td>0.002</td><td>NS</td><td>NS</td><td>NS</td><td>0.004</td></tr><tr><td>18-29 years</td><td>35.6</td><td>18.8</td><td>17.1</td><td>7.9</td><td>21.7</td><td>16.3</td><td>5.9</td><td>4.2</td><td>2.5</td><td>4.2</td></tr><tr><td>30-39 years</td><td>27.2</td><td>13.5</td><td>11.5</td><td>6.3</td><td>13.9</td><td>9.6</td><td>4.3</td><td>2.9</td><td>1.9</td><td>1.9</td></tr><tr><td>40-49 years</td><td>27.3</td><td>13.5</td><td>12.3</td><td>6.7</td><td>15.9</td><td>15.3</td><td>5.0</td><td>3.7</td><td>3.1</td><td>0.6</td></tr><tr><td>50-59 years</td><td>31.3</td><td>18.6</td><td>15.2</td><td>6.8</td><td>19.5</td><td>6.8</td><td>3.4</td><td>4.2</td><td>5.9</td><td>0.0</td></tr><tr><td>60-74 years</td><td>23.2</td><td>10.5</td><td>9.3</td><td>4.0</td><td>14.5</td><td>4.1</td><td>1.2</td><td>1.7</td><td>2.9</td><td>0.0</td></tr><tr><td>Marital status (p)</td><td>0.0008</td><td>0.04</td><td>NS</td><td>NS</td><td>NS</td><td>NS</td><td>NS</td><td>0.03</td><td>NS</td><td>0.003</td></tr><tr><td>Single</td><td>27.8</td><td>18.6</td><td>16.4</td><td>8.3</td><td>20.5</td><td>13.6</td><td>4.3</td><td>5.3</td><td>2.8</td><td>3.6</td></tr><tr><td>Married</td><td>24.1</td><td>13.0</td><td>12.1</td><td>5.1</td><td>14.8</td><td>9.0</td><td>3.3</td><td>1.6</td><td>3.5</td><td>0.5</td></tr><tr><td>Separated</td><td>31.6</td><td>15.5</td><td>8.6</td><td>8.6</td><td>18.9</td><td>13.8</td><td>10.3</td><td>5.2</td><td>0.0</td><td>0.0</td></tr><tr><td>Widowed</td><td>20.0</td><td>6.0</td><td>6.0</td><td>2.0</td><td>12.0</td><td>6.0</td><td>4.0</td><td>2.0</td><td>4.0</td><td>0.0</td></tr><tr><td>Employment (p)</td><td>0.04</td><td>NS</td><td>NS</td><td>NS</td><td>0.01</td><td>NS</td><td>NS</td><td>NS</td><td>NS</td><td>NS</td></tr><tr><td>Employed (n = 503)</td><td>26.5</td><td>13.3</td><td>11.7</td><td>5.7</td><td>14.5</td><td>11.1</td><td>3.2</td><td>2.9</td><td>3.6</td><td>0.99</td></tr><tr><td>Unemployed (n = 397)</td><td>32.6</td><td>17.1</td><td>15.1</td><td>7.3</td><td>20.6</td><td>10.8</td><td>5.4</td><td>3.7</td><td>2.3</td><td>2.5</td></tr></tbody></table>

NS = non-significant

comparisons between locations and subsequent adaptations of local mental health policies.

Replication studies are required, especially for comparison between French and English Caribbean islands. Specific studies in the Caribbean population living in mainland France may be relevant.

In conclusion, our study found that mental disorders, especially mood and anxiety disorders, were as prevalent in Martinique as in mainland France. These results should strengthen the development of a system of diagnosis and care for these disorders, especially to prevent suicidal behaviours and reduce morbidity and mortality.

## ACKNOWLEDGEMENTS

This survey was carried out in collaboration with Colson Psychiatric Hospital, the University Hospital of Fort-de-France, the Institute for Training in Nursing and the Regional Health Observatory of Martinique. It was funded by Colson Psychiatric Hospital, the Regional Council and the Direction of Health and Social Development.

The authors would like to thank local coordinators (N Ballon, S Merle, G Ursulet), local supervisors (M Assogba, R Brunod, B Cazenave, JP Desbeuf, B Delille-Manières, M Dietsch, JD Even, E Guillaudat, N Nelzy, S Nogard, F Oliny, M Paris, V Petit-Jean-Roget),

and interviewers (M Assogba, N Assogba, N Ballon, K Bonnialy, J Brissit, S Bucher, S Chatenay, J Conne-Bizy, F Cyrille, L Dambo, J Denis, E Guillaudat, M Elisabeth, R Eridan, T Gerald, C Hayot, MC Jean, T Lacrampe, A Latouchent, S Louison, R Marie-Anne, MA Marine, S Merle, M Michalon, F Montredon, N Nelzy, F Oliny, M Paris, S Paulin, R Robert, J Rosine, O Terosier, G Ursulet, N Verroux, MN Vitulin).

The SPMG was carried out by the WHO-CC. The scientific coordinator was JL Roelandt. The methodologic coordinator was A Caria. The general coordinators were A Kergall (foreign centres) and G Mondière (French centres).

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