Study on frequency of Depression and factors affecting ......Residential areas of Karachi that we...

International Journal of Advancements in Research & Technology, Volume 2, Issue 7, July-2013 342 ISSN 2278-7763

Copyright © 2013 SciResPub. IJOART

Study on frequency of Depression and factors affecting mood in women

Of age 18-66 years residing in Karachi using Patient Health Questionnaire-9

Authors:

Dr. Zaheen Baig Sajjad (Assistant Professor of Community Health Sciences, Bahria University Medical and Dental College, Karachi)

Nayab Shakil (4th year student, Bahria University Medical and Dental College, Karachi)

Yumna Khan (4th year MBBS student, Bahria University Medical and Dental College, Karachi)

Address for Correspondence:

Dr. Zaheen Baig Sajjad

Email: [email protected]

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mailto:[email protected]



ABSTRACT

Background: Women in this part of world being less educated are prone to develop mental and physical disorders as they are unable to cope up with daily stresses of life. Hence, there is a need to find out factors related to depression in them.

Objective: To study the frequency of Depression and factors affecting it in working and household women (18 to 66 years) of Karachi using Patient Health Questionnaire-99

Methods: A cross-sectional study was conducted on women (18 to 66 years) of Karachi. Sample size was 454 (227 household and 227 working women). Women underwent a face to face interview; housewives were interviewed at home and working women in their offices.

Results: Overall frequency of depression found in women of Karachi was 38.7%. Our working women 91/227(40.09%) were found to be more depressed than household women81/227(35.7%).

Conclusion: Study showed that more working women are depressed as compared to housewives, as was expected. The problems they faced were family issues, financial problems and extra workload

Keywords: Depression, middle age, socioeconomic, peer pressure, bipolar disorder.

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INTRODUCTION

Depression is a state of low mood and aversion to activity that can affect a person's thoughts, behavior, feelings and physical well-being. Depression is a common mental health problem, seen frequently in general medical settings [1].

Psychosocial and environmental stressors are known risk factors for depression. NIMH (National Institute of Mental Health) research has shown that stress in the form of loss, especially death of close family members or friends, can trigger depression in vulnerable individuals [2]. Genetics research indicates that environmental stressors interact with depression vulnerability genes to increase the risk of developing depressive illness. Stressful life events may contribute to recurrent episodes of depression in some individuals, while in others depression recurrences may develop without identifiable triggers [2].

Depression affects both men and women, but more women than men are likely to be diagnosed with depression in any given year [3].There is considerable evidence demonstrating that stressful life events are closely associated with depression and such events are more common in the lives of women .Thus, women are far more likely to be victims of violence in their homes [4]. The multiple roles played by women such as child-bearing, running the family home, caring for sick relatives and, in an increasing proportion of families, earning income, may lead to considerable stress.4Moreover, the stressful events of law and order also effect women as they are found to be more emotional and easily carried away by even smallest law and order situation.

Depressive disorders, of which the best known and mostly research upon which has been done is Major Depressive disorder (MDD) commonly called clinical depression or major depression, and Bipolar Disorder (BD), formerly known as manic depression and described by intermittent periods of manic and depressed episodes[1].

Major depressive disorder (also known as recurrent depressive disorder, clinical depression, major depression, unipolar depression or unipolar disorder) is a mental disorder characterized by an all-encompassing low mood accompanied by low self esteem, and by loss of interest or pleasure in normally enjoyable activities [1].

The symptoms of depression, such as poor concentration, low mood, and lack of interest, or pleasure affect the patient’s capabilities for work and logical communication, and may lead to suicide [5].

Bipolar disorder or manic-depressive disorder, which is also referred to as bipolar or manic depression, is a psychiatric diagnosis that describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated energy levels, cognition, and mood with or without one or more depressive episodes[1].

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It is pertinent to note that political situation in Pakistan is ever changing. This has taken a toll on common man’s nerves. The prevalence of depressive disorders appears to be particularly high among women, where several studies have shown the close association of depression with socio-economic adversity, relationship problems and lack of social support [6] and statistics showed that 35.6% households suffer from depression in Karachi [7]. Mean overall prevalence of anxiety and depressive disorders in the community population was 34% (range 29-66% for women and 10-33% for men) [8]. Factors positively associated with anxiety and depressive disorders in Pakistan were female sex, middle age, low level of education, financial difficulty, being a housewife, and relationship problems [6]. Those who had close confiding relationships were less likely to have anxiety and depressive disorders [8]. Signs and symptoms of depression in women are depressed mood , loss of interest or pleasure in activities you used to enjoy ,feelings of guilt, hopelessness and worthlessness ,suicidal thoughts or recurrent thoughts of death ,sleep disturbance (sleeping more or sleeping less) ,appetite and weight changes, difficulty concentrating ,lack of energy and fatigue[6].

Many women with a depressive illness never seek treatment. But the vast majority, even those with the most severe depression, can get better with treatment.

MATERIALS AND METHODS

Setting:

Data was collected from Karachi. We visited shopping mall, residences, banks, schools, universities, hospitals of Karachi according to our convenience.

Residential areas of Karachi that we visited were Karsaz, N.O.R.E 1, Malir,Gulshan-e-Iqbal,North Nazimabad, Gulistan-e-Jauhar, Rabia City Apartments, Defence Housing Authority, Phase 2,Askari- 4, Clifton.

Banks that we visited were Allied Bank, Clifton branch,Standard Chartered Bank,Shahrah-e-Faisal Branch.

We also went to PNS Shifa Hospital, D.H.A.

Shopping malls of Karachi that we visited were Millennium Mall, Dolmen Mall, Tariq Road, Park Towers, Gulf Shopping Mall and Sunday Bazaar

Study period:

July-October 2010

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Study Design:

Cross sectional

Sample Technique

Convenient sampling

Sample Size

A study conducted in Karachi in 2007 showed that 35.6% of household suffer from depression [9].Plugging this prevalence value in the sample size formula, our sample for household women came out to be 350. We just doubled the sample so as to cover the working women.

P= z2 (pq)/e2

Hence with z=1.962, p=0.35, q=0.65 and e=.052

p=1.962(.35) (.64)/.052 = 349.58

Thus our sample size was calculated to be 700 in total (350 housewives and 350 working women). However due to limitation of time and resources we conducted our study only on a sample of 454 women (total).

Inclusion criteria: We included healthy women of 18 to 66 years of age. Exclusion criteria: Those women suffering from any serious acute or chronic illness (on history) were excluded.

Dependent variable: Our outcome or dependent variable of the study is “Depression” in women.

Independent Variables • Age(years) • Family Income(Rs/month) • Marital Status (Single/married/divorced/widow) • Occupation: (Doctor/Nurse/Teacher/Banker/Servants/housewife/saleswoman/any other) • Family Issues (yes/no) • Financial problems (yes/no) • Work Load (yes/no) • Peer pressure (yes/no) • Any other(chronic disease, post partum period, central nervous system disorder)

Data Collection

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We conducted the questionnaire both through face to face interview and self reporting. Women who were educated were given the liberty of filling-in themselves whereas women who were not confident of themselves were helped by us in doing the same.

Instrument We adapted our questionnaire from Patient Health Questionnaire-9[9]. Some questions

related to those factors affecting mood were added so as to make some necessary changes according to our culture/social set up.

RESULTS

In our sample of 454 women, we found mean age of about 36.5 years.

Mean family/household income of these women was found to be about Rs. 65,055 per month.

According to the responses given by our women, about (180/454)39.6% never felt any change in level of interest in doing daily work We found that about 185/454(40.7%) of women never felt any feeling of hopelessness.About 181/454(39.9%) women did not enjoy their sleep and felt some change in sleep pattern several days in a week. We found that about 174/454(38.3%) women felt tired for several days in a week. About 159/454(35.2%) felt change in eating habits for several daysin a week.About 160/454(35.24%) felt bad about themselves several days in a week. About (154/454)33.9% felt trouble in concentrating on their work for several days. We found that about (170/454)37.4% of study women moved or spoke so slowly that people around them hardly notice them or they hardly notice people around them. On enquiring we found that about 187/454(41.2%) women never tried to kill themselves or thought that they would be better off dead. Similarly on enquiring about them handling their problems, about 194/454(42.7%) women answered that these problems made their life “somewhat difficult”

We found that Depression was highest among the age group of 46 to 52 years (in about 18/31(58%))

In our study Depression was seen to be highest in widows (about 19/34(55.9%) women).

We found that women having family income of up to 20,000 Rs were the most depressed. This was our lowest income hence most poor of the whole lot.

About 123/227(54%) working women complained of having family issues although they were better off in terms of family income. Interesting to note, about 90/227(39.6%) working women complained of financial burden in spite of being blessed with a personal income.

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About 98/227(43.1%) working women complained of too much work load physically and mentally. About 83/227(36.5%) household women felt pressure from their peers usually who were their elders in the family like their parents-in-law or parents etc.

DISCUSSION

In our study, overall frequency of depression was found to be about 176/454 (38.7%).This figure is similar to another study carried out in semi-urban squatter settlements of AzamBasti, Karachi, whereby they reported an apparent prevalence of 30% in study population [10].

Our prevalence is consistent with the general figure for developing countries where about 10–44% of people suffer from depression and anxiety [11]. Looking at the frequency of depression in our two groups of women, it was about 85/227(37.5%) in household women, which is quite similar to that given in another study [8] while in working women it was about 91/227(40.09%).The prevailing situation in Pakistan along with dearth of health facilities has created a ground fertile for anxiety and depression. .

In our study problems faced by household depressed women were mainly socioeconomic which is consistent with another study conducted by Rabia and Huma[5]wherein about 104/227(45.8%) household women had family problems, about 57/227(25.1%) household women had financial problems. about 84/227(37%) household women had workload. Needful to say, our women belong to mostly well to do or richer family background as mean family income is 65,055Rs

It is seen that working women try to juggle careers with their home or family. Although women may make less money than men, they appear to work more hours per week than men when all the roles that they perform are considered. Women often work full time in the paid workforce and do nearly all the child care and domestic work of the home. This in itself can be a source of anxiety and can lead into depression [12][13]. In addition women are increasingly "sandwiched" between caring for young children and caring for sick and older family members. This work overload is proposed to contribute to a sense of burnout and general distress, including depressive symptoms, in women [14].

We found that women who had lower family income were the most depressed. It is to be noted that we considered income of their husbands as the income of the housewives. This is because housewives due to other priorities are unable to give a helping hand in this regard.

In our study Depression was found to be more in widows. Most of them i.e about 19/34(55.9%) widows complained of financial problems. They being left with nobody to care for them and themselves not able to work fall prey to monetary scarcity.

We found that Depression was highest among the age group 46 to 52 years in about 18/31(58%) women whereas the mean age of sufferers was 36.8 years in a different study [9].Age related

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decline in central serotonergic function might make older individuals more vulnerable to depression and possibly render depressive episodes more frequent with increasing severity and being less amenable to treatment[15] In a study[16] it was described that depression reaches its lowest level in the middle age at about age 45, rise in late life reflecting life cycle gains and losses in marriage, employment and economic well being. The issue of what is called middle age is interesting. Local definitions quote a range from 40–59 years as ‘middle age’, however, the argument can be put forward as to what is called ‘middle age’ may vary according to the measured life expectancy at birth in different countries. In Pakistan, the life expectancy at birth for males and females is 61 and 63 years respectively, in this regard, the mean age of sufferers may qualify for being in this category.

When older women do suffer from depression, it may be overlooked because older adults may be less willing to discuss feelings of sadness or grief, or they may have less obvious symptoms of depression. As a result, their doctors may be less likely to suspect or spot it.

For older adults who experience depression for the first time later in life, other factors, such as changes in the brain or body, may be at play. For example, older adults may suffer from restricted blood flow, a condition called ischemia. Over time, blood vessels become less flexible. They may harden and prevent blood from flowing normally to the body's organs, including the brain. If this occurs, an older adult with no family or personal history of depression may develop what some doctors call "vascular depression." Those with vascular depression also may be at risk for a coexisting cardiovascular illness, such as heart disease or a stroke [17].

Most of the working women, about 33/227(14.3%) had Major Depressive Disorder in our study (sometimes also referred to as clinical depression or major depression) must either have a depressed mood or a loss of interest or pleasure in daily activities consistently for at least a 2 week period also. Major depressive disorder generally cannot be diagnosed if a person has a history of manic, hypomanic, or mixed episodes (e.g., a bipolar disorder) or if the depressed mood is better accounted for by schizoaffective disorder and is not superimposed on schizophrenia, a delusion or psychotic disorder. Typically the diagnosis of major depression is also not made if the person is grieving over a significant loss in their lives [18].

First-degree biological relatives of individuals with Major Depressive disorder are 1.5-3 times more likely to develop Major Depressive Disorder. They also have an increased risk of having Alcohol Dependence, Anxiety Disorder (e.g., Panic Disorder, Social Phobia), and Attention-Deficit/Hyperactivity Disorder compared with the general population [19].

Most of the household women, about 40/227(17.6%) household women had other types of depression in our study: dysthymia, bipolar disorder, Atypical depression, psychotic depression, premenstrual dysphoric disorder, Seasonal Affective Disorder, postpartum depression, post menopausal depression, biochemical depression, disease or drug related depression[20][21].

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Study strengths and weaknesses

In our study we were able to look at depression in two distinct types of women, those who were housewives and those who were working. We had the advantage of interviewing working women in their offices.

We interviewed mostly women of higher socioeconomic class or women who were better off because it was convenient for us to reach them.

We interviewed all women for their problems, although it would have been better if we would have separated out depressed women from healthy ones and only probed the depressed women for their problems.

We did not collect information on menstrual history of women, although it would have helped us in knowing about the women suffering from other types of depression i.e premenstrual dysphoric disorder, postpartum depression etc.

We could not score the severity of depression of women as it was required to set treatment goals.

CONCLUSION

We found that more working women are depressed as compared to housewives. The problems they pointed out were family issues, financial problems and workload.

RECOMMENDATION

There is a need to educate women so as to cope with life stress. Media should play its role in this regard.

REFERENCE 1. http://en.wikipedia.org/wiki/Depression_ (mood) (Date accessed: 20/8/2010)

2. Research on Depression by James Hunter and NIMH. Available at http://psychcentral.com/disorders/depressionresearch.htm

3.Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, Rush AJ et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). Journal of the American Medical Association. 2003; 289(3): 3095-3105.

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4. Women’s Mental Health: A Public Health Concern: R.Thara and V.Patel Regional Health Forum WHO South-East Asia Region (Volume 5, Number 1) available at http://www.searo.who.int/en/Section1243/Section1310/Section1343/Section1344/Section1353_5282.htm 5. Surveillance of depression in Karachi, Pakistan Rabia Bushra, M.Phil.B.Pharm, HumaAli, M.Phil.B.Pharm. Available at http://www.emro.who.int/imemrf/Neurosciences_2009_14_2_193.pdf

6. Depression in Women Causes, Symptoms, and Treatment Melinda Smith, M.A., and Jaelline Jaffe, Ph.D., contributed to this article. Reviewed by Jeanne Segal, Ph.D. Last reviewed: May 2010. 7. Prevalence of Depression among Households in Three Capital Cities of Pakistan: Need to Revise the Mental Health Policy. Amin A. Muhammad Gadit, Gerry Mugford [PubMed]

8. Risk factors, prevalence, and treatment of anxiety and depressive disorders in Pakistan: systematic review Ilyas Mirza, s, Rachel Jenkins. BMJ 2004; 328:794

9. The PHQ-9: A New Depression Diagnostic and Severity Measure by Kurt Kroenke, MD; and Robert L. Spitzer, MD. Available from : http://www.depression-primarycare.org/clinicians/toolkits/materials/forms/phq9

10. Ali BS, Amanullah S. Prevalence of Anxiety and Depression in an Urban Squatter settlement of Karachi. J Coll Physicians Sur Pak 2000; 10:4-6.

11. W.H.O. (2001) World Health Report, Geneva, Switzerland. (Date accessed 24 /72010)

12. Barnett, R. C, Brennan, R. T., & Marshall, N. L. (1994). Gender and the relationship between parent role quality and psychological distress: A study of men and women in dual-earner couples. Journal of Family Issues, 15, 229-252.

13. Crosby, F. J. (1982). Relative deprivation and working women. London: Oxford University Press.

14. Nolen-Hoeksema S, Larson J, Grayson C. Explaining the gender difference in depressive symptoms. Journal of Personality and Social Psychology. 1999; 77(5): 1061-1072.

15. W.H.O. Mental Health Atlas, revised edition, Geneva, Switzerland. 2005. (Date accessed 26/7/2010)

16. Lerer B, Gillan D, Lietenberg P, Gorfine M, Gelfin Y, Shaperia B. Inter relationship of age, depression and central serotonergic function: evidence from fenfluramine challenge studies. IntPsychogeriatr, 1996;8(1):83–102.[PubMed]

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http://www.depression-primarycare.org/clinicians/toolkits/materials/forms/phq9



17. Krishnan KRR, Taylor WD, McQuoid DR, MacFall JR, Payne ME, Provenzale JM, Steffens DC. Clinical characteristics of magnetic resonance imaging-defined subcortical ischemic depression. Biological Psychiatry. 2004 Feb 15; 55(4): 390-397. 18.http://psychcentral.com/disorders/sx22.htm Last reviewed: By John M. Grohol, Psy.D. on 1 Jun 2010

19. Article on Major Depressive Disorder available at: http://www.mentalhealth.com/dis/p20-md01.html. Date accessed: 22/4/2012

20. Understanding Depression by Betty Burrows, PhD. Available at: http://health.howstuffworks.com/mental-health/depression/facts/understanding-depression-ga1.html

21. Article on different types of depression. Available at: http://www.all-on-depression-help.com/different-types-of-depression.html

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http://psychcentral.com/disorders/sx22.htm

http://www.mentalhealth.com/dis/p20-md01.html.%20Date

http://www.mentalhealth.com/dis/p20-md01.html.%20Date

http://health.howstuffworks.com/mental-health/depression/facts/understanding-depression-ga1.html

http://health.howstuffworks.com/mental-health/depression/facts/understanding-depression-ga1.html

http://www.all-on-depression-help.com/different-types-of-depression.html

http://www.all-on-depression-help.com/different-types-of-depression.html



Table 1: Demographic characteristics of women

Variables Depression No depression Total(n=454) Frequency(n) Percentage(%) frequency Percentage(%)

Marital status Married 108 36.2 190 65.7 298 Single 33 37.9 54 62 87 Divorced 16 45.7 19 54.3 35 Widow 19 55.9 15 44 34 Income groups

0-20000 49 46.6 56 53.3 105 20001-40000 25 34.7 47 65.3 72 40001-60000 30 42.8 40 57.1 70 60001-80000 20 30.3 46 69.6 66 80001-100000 35 40.2 52 59.8 87 100001>100001

17 31.5 37 68.5 54

Age groups

18-24 31 38.8 49 61.3 80 25-31 38 35.2 70 64.8 108 32-38 42 40 63 38 105 39-45 35 39.8 53 60.2 88 46-52 18 58 13 41.9 31 53-59 9 29 22 70.9 31 60-66 3 27.2 8 72.7 11

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Table 2: shows the type of depression in working and household women

Type of depression

Household women(n)

Percentage(%) Working women (n)

Percentage(%)

Depressive disorder

22 9.6 31 13.7

Major depressive disorder

22 9.7 33 14.5

Other depressive disorder

40 17.6 27 11.9

No depressive disorder

143 63 136 60

Type of depression:

Depressive disorder: 53/454(11.7%)

Major depressive disorder: 55/454 (12.1%)

Other depressive disorder: 67/454 (14.8%)

No depressive disorder: 279/454 (61.5%)

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Figure 1: showing percentage of different types of depression prevailing in both household and working women

12%

12%

15% 61%

type of depression

depressive disorder major depressive disorder

other depressive disorder no depressive disorder

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Table 3: Frequency of problems faced by women:

Problems Household (n=227)

Percentage (%)

Working(n=227) Percentage(%)

Family issues Yes No Financial problems Yes No Work load Yes No Peer pressure Yes No

104 111 57 170 84 143 83 144

45.8 48.9 25.1 74.9 37 62.9 36.5 63.4

123 116 90 137 98 129 67 160

54 51.1 39.6 60.3 43.1 56.8 29.5 70.48

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Table 4: Table showing the response of the women to the Patient Health Questionnaire-99

Variables Frequency(n=454) Variables Less level of interest in doing daily work: Not at all Several days More than half the days Nearly every day Feeling of hopelessness: Not at all Several days More than half the days Nearly every day

Frequency(n) 180 147 91 36 185 150 84 35 165

Percentage (%) 39.6 32.3 20 7.9 40.7 33 18.5 7.7 36.3

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Change in sleep pattern: Not at all Several days More than half the days Nearly every day Feeling of tiredness: Not at all Several days More than half the days Nearly every day Change in eating habits: Not at all Several days More than half the days Nearly every day Feeling bad about yourself: Not at all Several days More than half the days Nearly every day Feeling trouble in concentrating on things: Not at all Several days More than half the days Nearly every day Do you move and speak so slowly that other people hardly notice you or the opposite? Not at all Several days More than half the days Nearly every day Attempted to hurt yourself or thought that you were better off dead: Not at all Several days More than half the days

181 89 19 154 174 85 41 138 159 105 52 158 160 96 40 148 154 116 36 159 170 105 20 187 141 93

39.8 19.6 4.2 33.9 38.3 18.7 9 30.4 35 23.1 11.5 34.8 35.2 21.1 8.8 32.5 33.9 25.5 7.9 35 37.4 23.1 4.4 41.2 31.1 20.5

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Nearly every day If you have checked off any problem, how difficult have these problems made it for you to do your daily work? Not difficult at all Somewhat difficult Very difficult Extremely difficult

33 108 194 115 37

7.3 23.8 42.7 25.3 8.15

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