Differences in the Functioning and Occupational Activity in People with Mental Disorders: A Gender Perspective

In Mexico during 2017 mental disorders (MD) represented 1,424.94 of Disability-Adjusted Life Years (DALYs) per 100,000 inhabitants, ranking 8th in the global burden of disease in the general population and in all age groups, they also occupy the first place with 18.98% of Years Lived with Disability (YLDs) according to the Institute for Health Metrics and Evaluation [1]. The most Received: November 20, 2019 Published: December 02, 2019


Introduction
In Mexico during 2017 mental disorders (MD) represented 1,424.94 of Disability-Adjusted Life Years (DALYs) per 100,000 inhabitants, ranking 8th in the global burden of disease in the general population and in all age groups, they also occupy the first place with 18.98% of Years Lived with Disability (YLDs) according to the Institute for Health Metrics and Evaluation [1]. The most prevalent MD in Mexico are depression (4.66%), anxiety (3.09%), substance use (2.28%), alcohol use (1.77%), bipolar disorders (1.72%) and schizophrenia (1.39%). The MD involve suffering and functional deterioration so they cannot only be understood as the presence of psychopathological signs and symptoms, it should also be considered the degree of disability associated with them [2]. The high levels of disability caused by the MD limit the individual and social functioning of the patient, such as having a job [3]. The disability associated with MD leads to negative economic consequences derived from direct costs for the care of the disease and indirect cost such as those associated with loss of productivity of the patient and primary caregiver [4].
Which places these patients in a situation of social inequality due to high unemployment rates; in fact, one study estimated the economic decline due to schizophrenia at 2.7 billion euros, of which 50.5% are due to indirect costs such as the loss of productivity of the affected person, loss of productivity of caregivers and compensation for disability; and 49.5% due to direct costs [5].
Another study associated the loss of productivity with the continuity of treatment in anxious and depressed patients [6]. Therefore, the disability associated with mental disorders is a challenge that lies in understanding the relationship of the psychopathology of mental disorder and disability to be able to identify and intervening in early stages of the disorders in order to improve the prognosis and the economic consequences [7]. In this perspective, this study examines the relationships between the specific domains of daily functioning through the World Health Organization-Disability Assessment Schedule (WHODAS 2.0) with gender, diagnosis, and occupational activity in people with mental disorders.

Methods
Study design. A cross-sectional study was carried out using the survey technique. The study was approved by the Ethics and Research Committee of the Fray Bernardino Alvarez Psychiatric Hospital (HPFBA initials of Hospital Psiquiátrico "Fray Bernardino Álvarez"), and was carried out during the second semester of 2017; the research followed the principles of the Declaration of Helsinki and all the participants signed an informed consent.

Sample
The participants were selected from the HPFBA, who met the following selection criteria: 1) Men and women over 18 years of age who received medical attention for a MD at the institution during the study time; 2) Have the presence of a responsible relative, legal representative or primary caregiver;

3)
Agree to answer the survey and sign the informed consent.  and/or school responsibilities; and Do6: participation in society, getting involved in community activities [8]. In the present study, the version of 36 questions administered by the interviewer was used, since it allows evaluating both the levels of functionality and disability in general, and specifics for each domain. Most of the questions are developed in the Likert format, where an ascending scale is exposed, which usually ranges from the first option "None" to the fifth "Extreme or cannot do it", according to the level of difficulty that the interviewee reports to perform different activities.

Statistic Analysis
Derived from the frequency distribution of the variables and measures of central tendency and variability measures were applied (mean deviation, standard deviation); bivariate analysis for association considering all the variables and indicators included in the mentioned instruments such as sex, diagnosis and occupational activity. To obtain performance and disability scores through WHODAS 2.0, the simple form lists the response options from 1 to 5 (being "None" = 1, and "Extreme or can not do it" = 5) and add up the points according to what the participant answers: the higher the grade, the greater the disability; in the complex score, the answers are weighted according to the different questions and levels of severity, from which the qualifications of each option are recoded; subsequently the sum of the points obtained globally and by domain is made. This process is carried out electronically, through the application of an algorithm developed by the WHO for the statistical analysis program SPSS, where a score between 0 (without disability) and 100 (total disability) is generated; for our analysis we used the complex method [10,11]. For the categorization of the WHODAS 2.0 score, the CIF methodology was resumed in the following way: 0 -4% no disability, 5 -24% mild, 25 -49% moderate, 50 -95% serious and 95 -100% complete [12]. We applied t test to know the

Results
The sample consisted of n = 302 patients with an average age of 33.4 years (SD = 11.75) of which 62.9% were men, with an average 9.6 years of schooling (SD = 3.98). In relation to marital status only 14.6% were married. Regarding the place of origin, the patients were mostly residents of Mexico City (55.6%), and the state of Mexico (37.1%). For the diagnostic classification it was first obtained through the ICD-10 [13], once obtained, they were grouped according to the first digit obtaining the following diagnostic groups: schizophrenia 48% (n = 145), other psychotic disorders 19.9% (n = 60), personality disorders 8.9% (n = 27), bipolar disorder 8.6% (n = 26), depressive disorders 8.3% (n = 25), non-specific mental disorder 3.3% (n = 10) and anxiety disorder 3% (n = 9). Regarding of the occupational activity the majority of participants did not have a job and this due to health problems with 48.7% (n = 147) of which 22.4% were women (n = 33); or they had a self-employment with 16.2% (n = 49) of them 38.8% corresponded to women; 12.9% (n = 39) of them 38.5% of women they did not have employment for reasons other than having health problems; 8.6% mentioned dedicating themselves to household activities as an occupational activity (n = 26, of which 96.2% corresponded to women); 7% (n = 21, of which 42.9% corresponded to women) had formal employment, and the remaining 6.6% (n = 20, where 55% corresponded to women) were classified as students. In the bivariate analysis there were differences in relation to gender and marital status ( = 15.56, p = .000); between gender and occupation ( = 55.51; p = .000); and between the gender and the diagnosis ( = 37.49, p = .000).
Regarding to the levels of disability and functioning, the  (Table 1).   indicates that all the groups of domains of functioning differ among themselves according to the occupational activity; observing the greater functioning in activity as "student" when compared with the occupational activity " unemployment for health condition" or "unemployment due to health reasons" (p = .002); and the lower performance in the activity "self-employment", as compared to the activity "unemployment for health condition" (p = .000) ( Table 3).   Note: *Statistically significant values. Do1 = Cognition Do2 = Mobility: getting around Do3 = Self-care Do4 = Getting along Do5 = Life activities: Do5 1 = Household, Do5 2 = Work or school Do6 = Participation in society St_32 = Global WHODAS 2.0.

Discussion
The results of our study are relevant in the sense that it reports the degree of affectation of the different domains of functioning in people with different mental disorders, in the understanding that disability is the main predictor of the needs of health care and services, however, it is not commonly evaluated [14]; such is the case that there are no defined standards or thresholds [15]. Although all functioning domains are affected in this population, the degree of differentiated involvement by domains is very notable, we find levels of severe disability (values of more than 50 % disability), in the domains of participation in society and interpersonal getting along (relationship), which have a logic with the way of presentation and evolution of mental disorders, especially in those considered serious as schizophrenia and other primary psychotic disorders [16], in which we observe a decrease in social functioning much earlier than symptomatic appearance, mainly the one that demands social interaction. We also found moderate disability (those domains with disability levels between 25 and 49%), in the domain of cognition and activities at home; regarding these observed data, we know that mental disorders are the cause of various cognitive dysfunctions (abilities to pay attention, remember, process information, solve problems, organize and reorganize information, communicate and react to received information) and are often the primary symptom in psychotic disorders [17], for example in the schizophrenia the executive functions components have been associated with the general measure of functional outcome, by the way, studies have suggested that cognitive task performance can be broken down into the same broad domains in both schizophrenic and other populations (like healthy population) [18].
Respect to life activities which is divided into two, on the one hand activities at home and on the other hand activities at work or school, higher disability score was observed in activities of the home, most of the patients in our study do not have a job, nor do they study, therefore the perception of functioning is not dependent on the area in which they are located. Another relevant finding of our study is that these levels of disability are different by gender; Despite the fact that this difference in the mobility disability is significant in the understanding that women have higher prevalence than men in painful symptoms without medical explanation that cause disability or are associated with affective or anxious mental disorders [19]. The fact of finding these differences in the levels of disability between men and women, forced us to carry out an exhaustive analysis according to the mental pathology and the main work activity that they reported. When comparing the differences in disability between the different mental disorders, the average disability in the groups of schizophrenia and other primary psychotic disorders is enormous compared to the anxiety disorders which are considered common mental disorders, although they are the most prevalent in the population, it was not so in our study sample; we could observe that the most prevalent diagnosis was schizophrenia with almost 50%, a condition that was observed more in men (with prevalence greater than 70%).
Having schizophrenia and other psychotic disorders leads to disability in almost all domains of functioning, as has been reported in other studies [20,21]. We observe great differences especially in the domains of cognition, participation in society, and above all and at a higher score the domain of life activities such as household, and this difference in functioning is only observed in a significant way at a global level (st_32), but only in the sample of those who do not study or work, like most of the people in this study, in other words, when people with mental disorders perform activities that keep them busy productively, such as a job, these differences in their functioning are not observed globally (st_36), as reported in another study, unemployment is not only caused by having a mental disorder, but not having a job can also generate a mental disorder [22]. Due to the above-mentioned, the results of disability It would be necessary to carry out validation studies and confirmatory analysis of the domains of functionality of the WHODAS 2.0 in the population with mental disorders, but differentiated by age groups and time of evolution of the mental disorder, before and after the treatment, this in order to establish points of cutting (standards and thresholds) and designing specific intervention strategies that turn towards favoring the domains of global functioning of people with mental disorders differentiated by gender.
Work integration can be difficult for people with a psychiatric disability such as schizophrenia, bipolar and depressive disorders, even though the majority of people with a psychiatric condition can and would like to work [23]. However, systematic research is needed to understand the individual and organizational factor that can affect the work productivity is stable across time [23]. In other hand, to increase awareness of the meaning and characteristics of strategies can inform a person-oriented approach in rehabilitation, the knowledge can be used in clinical encounters to reflect together with the patient, exploring present options and introducing modifications to their particular work and life context [24].
Self-managed work functioning in common mental disorders involves diverse strategies interpreted as sustainable over time, seem to be reflective in the sense that the worker consciously applies and adapts these strategies [24]. In conclusion, in people with mental disorders the level of functioning is seriously affected in the domains of cognition, participation in society and especially in everyday activities (chores at home), which is associated with high rates of unemployment and economic burden further exacerbates the prognosis. Men suffer higher levels of disability in general, but women show greater affectation of the mobility domain, which forces to jointly evaluate not only the symptoms of mental pathology, but the degree of disability that entails, in order to offer interventions multidisciplinary focused on the needs of the person and with a gender approach, which impact on improving the health condition of the affected population.