Abstract

Mental health disorders, such as depression and anxiety, pose significant global public health challenges, contributing to 7.4% of disability-adjusted life years (DALYs) and 22.7% of years lived with disability worldwide. In low- and middle-income countries (LMICs) like Ethiopia, these burdens are exacerbated by limited healthcare infrastructure, pervasive stigma, and frequent exposure to covariate shocks such as droughts, armed conflicts, and price shocks. Ethiopia faces one of Africa’s highest mental health burdens, with 4.7% of the population affected by depression and 3.3% by anxiety, particularly impacting women in rural areas where over 80% of the population resides. Systemic barriers, including poverty, low education, and cultural beliefs attributing mental illness to supernatural causes, further limit access to care and exacerbate intra-household mental health disparities.
This study investigates the intra-household burden of mental health disorders in Ethiopia by eliciting symptoms of depression and stress from both spouses in married households. Drawing on a large household survey, we measure mental health outcomes using the Patient Health Questionnaire-9 (PHQ-9) and Perceived Stress Scale. Through within-household comparisons and pairwise correlation analyses, we examine differences in mental health outcomes and assess vulnerability and resilience to covariate shocks. Using a fixed effects framework, we model mental health outcomes by interacting respondent gender with exposure to shocks such as drought, armed conflict, and price shocks.
Our findings reveal critical insights into intra-household mental health dynamics. First, women report significantly higher rates of depression and stress symptoms than men, particularly in rural areas where caregiving roles and lower mental health literacy amplify their vulnerability. Second, spousal mental health outcomes are weakly correlated in rural and poor households, suggesting limited sharing of mental health burdens, likely due to socioeconomic constraints and cultural norms. In contrast, urban and non-poor households exhibit stronger spousal correlations and spillovers, indicating more equitable burden-sharing. Third, while droughts impact both spouses similarly, women are more vulnerable to price shocks, likely due to their role in managing household resources, but show relative resilience to armed conflicts, possibly due to gendered roles limiting their exposure to violence.
These findings highlight the importance of understanding intra-household dynamics to address mental health challenges in resource-constrained settings. Women’s disproportionate burden, particularly in rural and poor households, underscores the need for gender-sensitive interventions. The varying impact of covariate shocks emphasizes the necessity of tailored adaptation strategies to enhance household resilience. For instance, addressing women’s vulnerability to price shocks requires targeted economic support, while building on their resilience to conflict can inform community-based mental health programs. The study also highlights the role of urban settings in facilitating stronger spousal support, suggesting that urban-focused interventions may leverage existing social dynamics to improve mental health outcomes.
By filling a critical gap in the literature on intra-household mental health burdens in Africa, this research offers actionable insights for policy and practice. It underscores the need for community-based interventions that integrate mental health services into primary care while accounting for intra-household power dynamics, such as resource allocation and decision-making hierarchies. These interventions should prioritize reducing stigma, improving mental health literacy, and enhancing access to care, particularly for women in rural areas. By addressing the interplay of gender, culture, and socioeconomic factors, this study contributes to the broader discourse on mental health in LMICs and informs context-specific strategies to reduce the mental health treatment gap and build resilience against covariate shocks in Ethiopia and similar settings.