Author:
Dr. Nasir A
Ali, Assistant Prof. of Public Health, Faculty of Public Health and Tropical Medicine , Jazan
University ,
Saudi Arabia, 2017; e mail: [email protected]anu.edu.sa
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Abstract:
Depression is a common mental health disorder,
affecting more than 350 million people of all ages worldwide, according to the
World Health Organization (WHO). In 2001, the WHO identified depression as the
fourth leading cause of disability and premature death in the world. It is
projected to become the leading cause of burden of disease by 2030. This
descriptive cross sectional study was conducted at Jazan region ,Saudi Arabia
aiming at estimating point prevalence of depression among healthy adults, data
was collected by using standardized of PHQ-9
questionnaire and collected data was analyzed by using SPSS ver. 20. About 347
adults of age 20 up to 60 years old were participated in this study, 49% were
male and 51% were female, majority (70%) within the age group from 30 – 40
years old, 65 % were single, 35% were married, 62% were
students and 38% were emplotees. The study indicated that only 15% of subjects
had no symptoms of depression while 85% of subjects had symptoms of depression
varies from minimal symptoms to moderate
/ major depression, where 30% had Minimal symptoms,
27% had mild major depression and 28% had moderate / major depression.
Keywords:
Depression, PHQ-9, Jazan region ,Saudi Arabia.
1.1 Introduction:
Depression is a common mental health disorder, affecting
more than 350 million people of all ages worldwide, according to the World
Health Organization (WHO). In 2001, the WHO identified depression as the fourth
leading cause of disability and premature death in the world. It is projected
to become the leading cause of burden of disease by 2030. By the year
2020 depression would be the second major cause of disability adjusted life
years lost, as reported by the World Health Organization. Depression is a
mental illness which causes persistent low mood, a sense of despair, and has
multiple risk factors. Its prevalence in primary care varies between 15.3-22%,
with global prevalence up to 13% and between 17-46% in Saudi Arabia. Despite
several studies that have shown benefit of early diagnosis and cost-savings of
up to 80%, physicians in primary care setting continue to miss out on 30-50% of
depressed patients in their practices. Addressing the growing unmet need for developing better
understanding of psychiatric diseases including major depressive disorder (MDD)
in Saudi Arabia.A recent study published in the Journal of Clinical Psychiatry
highlighted the large gap in the Middle East region between the number of
people needing and actually receiving treatment for depression. Furthermore,
the World Health Organization notes more than 75 percent of people with
depression in developing countries are inadequately treated, with mental health
one of the most neglected, yet essential, development issues in achieving the
United Nations’ Millennium Development Goals one and five.Demonstrating the
local burden, in Saudi Arabia, more than 201,000 disability-adjusted life years
(DALYs) are lost from depression in a year. DALYs is a measure of overall
disease burden, expressed as the number of years of potential life lost due to
premature death and the years of productive life lost due to disability.
1.2 Methods and Materials:
This cross-sectional study was conducted at Jazan Region, Jizan,
Saudi Arabia. About 347 adults of age 20–65 years were selected randomly. Data were collected using PHQ-2 and PHQ-9 Arabic version validated
questionnaires for depression screening 42. Other
relevant demographic and personal data were also collected including age,
gender, profession, social class and marital status, self-administered
questionnaire were distributed online from 15 – 31 of March, 2017. Collected
data were analyzed by using SPSS ver. 20
The PHQ-2 and PHQ-9 (Table 1) were analyzed
in terms of calculating the severity scores for each question, for presence of
depression symptoms over the last 2 weeks. The score of severity of
depression varied between 0 (not present at all), 1 (present in several days),
2 (present more than half the days) and 3 (present nearly every day). The
severity score of PHQ-2 was calculated and ranged between 0–6 points. Also, the
severity score of PHQ-9 ranged between 0–27 points. The scores for PHQ-9 were
used to determine the presence of depression and its severity depend on the
following score ranges: 1–4 minimal depression, 5–9 mild, 10–14 moderate, 15–19
moderate to severe, and 20–27 severe 43. For
statistical analysis in our study, a person with minimal score (1–4) on PHQ-9,
was not considered has ‘depressed’?, and those with score???10 (moderate –
severe) were categorized needing medical treatment for cost-analysis. For
PHQ-2, presence or absence of depression was based on a score of 3 and above
out of 6 on the screening instrument 44. Table 1and 2.
Table 1.2.1
shows the Patient health questionnaire PHQ 2 depression level
PHQ-9
Points
No syndrome
0-4
Minimal
syndrome
5-9
Major
depression / mild
10 -14
Major
depression / moderate
15 – 19
Major
depression / severe
> 20
Table 1.2.2
shows Patient health questionnaire PHQ 2* & 9: screening instrument for
depression
Not at
all
Several
days
More
than half days
Nearly
everyday
For last
2 weeks how often have you been bothered by any of the following
problems?
3
2
1
0
1.
Loss of
interest
3
2
1
0
2.
Feeling
depressed
3
2
1
0
3.
Trouble
sleeping.
3
2
1
0
4.
Feeling
tired.
3
2
1
0
5.
Poor appetite
or eating.
3
2
1
0
6.
Loss of
self-esteem.
3
2
1
0
7.
Low level of
concentration.
3
2
1
0
8.
Low voice or
edgy.
3
2
1
0
9.
Suicidal
ideation.
The data was analyzed for all questions
estimating frequencies, percentages, means and standard deviations, where
applicable. The PHQ-9 scores were used along with various demographic
variables, for comparisons, using statistical tests including Chi-square an t
test.
1.4 Results:
Table 1 shows the distribution of subjects
according to the gender
N =
347
Gender
Fr.
%
Male
171
49.3
Female
176
50.7
Table 2 shows the distribution of subjects
according to the age group
N =
347
Age Group
Fr.
%
> 20 years
27
7.7
20 – 30
232
66.9
30 – 40
52
15.0
40 -50
29
8.4
50-60
7
2.0
Table 3 shows the distribution of subjects
according to the marital status
N =
347
Marital
Status
Fr.
%
Single
227
65.4
Married
120
34.6
Table 4 shows the distribution of subjects according
to the profession
N =
347
Profession
Fr.
%
Student
214
61.6
Employee
117
33.8
hosehold
16
4.6
Table 5 shows the distribution of subjects
Socio-demographic characteristics and their associations with depression
N =
347
Major
severe
Moderately
severe
Minor
symptoms
Minimal
symptoms
No
symptoms
%
Fr.
%
Fr.
%
Fr.
%
Fr.
%
Fr.
Gender
0
0
31.7%
53
29.3
49
28.1%
47
10.8
18
Male
0
0
32.1%
52
26.5%
43
30.9%
50
10.5%
17
Female
0
0
31.5%
58
31.5%
35
30.4%
56
9.2%
17
student
Professional
0
0
34.1%
44
26.4%
34
28.7%
37
10.9%
14
employee
0
0
31.2%
5
25.0%
4
25.0%
4
10.6%
35
household
0
0
29.5%
38
24.8%
32
31.8%
41
14.0%
18
Single
Marital Status
0
0
33.5%
67
30.0%
60
28.0%
56
8.5%
17
Married
0
0
29.2%
7
25.0%
6
29.2%
7
16.7%
4
low
Social class
0
0
32.7%
97
27.6%
82
29.6%
88
10.1%
30
Medium
0
0
12.5%
1
50.0%
4
25.0%
2
12.5%
1
high
Table 6 shows the distribution of subjects according
to the syndrome of depression
N =
347
PHQ-9
Fr.
Fr.
%
No syndrome
0-4
53
15.3
Minimal syndrome
5-9
103
29.8
Major
depression / mild
10 -14
93
26.9
Major
depression / moderate
15 – 19
98
28.0
Major
depression / severe
> 20
0
0
Total
347
100.0
Table 7 shows the
distribution of subjects according to the PHQ-2* & PHQ-9 test
N =
347
%
Fr.
66.9
259
10.
Loss of
interest
75.2
291
11.
Feeling
depressed
61.5
238
12.
Trouble
sleeping.
80.1
310
13.
Feeling
tired.
62.5
242
14.
Poor appetite
or eating.
59.2
229
15.
Loss of self-esteem.
47.3
183
16.
Low level of
concentration.
28.7
111
17.
Low voice or
edgy.
22.0
85
18.
Suicidal
ideation.
Figure 1 shows the distribution of subjects according to the
syndrome of depression and gender
Figure 2 shows
the distribution of subjects according to the syndrome of depression and
marital status
Figure 3 shows
the distribution of subjects according to the syndrome of depression and
profession
Figure 4 shows
the distribution of subjects according to the syndrome of depression and social
class.
1.5 Discussion
About 347
subject adults of age 20 up to 60 years old were participated in this study,
49% were male and 51% were female, majority (70%) within the age group from 30
– 40 years old, 65 % were single
and 62% were students. The study indicated that only 15% of subjects had no
symptoms of depression while 85% of subjects had symptoms of depression varies
from minimal symptoms to moderatemajor
depression, where 30% had Minimal symptoms,
27% had mild major depression and 28% had moderatemajor depression with the average of 28%. This finding
is greater to to that reported by Al Ibrahim et al., in their systematic review
in 2010 19 and another study conducted in 2007 39. while another
study conducted for adults found that the prevalence was 49.9%, of which 31% were mild, 13.4%
moderate, 4.4% moderate-severe and 1.0% severe cases 40.
Our findings provide no gender differences in the
prevalence and presentation of depressive symptoms, where this finding is
opposite to another study which found difference regarding to gender
Our study also found that there were no a
significant relationship between depression and gender . Different findings was
reported in many studies either local (Moataz
M et al 200718, 20, 22, 23
or international 4, 11, 52.
In this study we also found no significant
relationship of depressive symptoms with other demographic variables such as;
age, profession, marital status and social class, this findings was similar to
many international studies 4, 16, 18, 21,
In Saudi Arabia, prevalence has been estimated in
several studies, with rates varying in different populations, age groups,
times, and geographic locations. Psychiatric morbidity in primary care was
estimated in 1995 around 30-46% of the visiting patients 17.
In 2002, depression and anxiety disorders were noted around 18% among adults in
central Saudi Arabia 18.
Al Ibrahim et al., in 2010 showed an overall prevalence of 41% in a systematic
review on depression 19.
El Rufaie et al., noted a 17% prevalence of depression among residents of
Dammam 20.
Al Qahtani et al., in Asir reported a 27% prevalence of depression in the year
2008 21.
Abdul Wahid et al. in 2011, reported an overall prevalence of depression
nearing 12%, with 6% as severe cases, in the south-eastern region 22.
In Riyadh Becker et al., found depression prevalence to be 20% in primary care
settings 23, 24.
Saudi Arabia has a high prevalence of depression,
and as population grows, along with rising risk factors of depression such as
chronic disease, stress of modernization, sedentary life style and social
isolation, coupled with pre-existing stigmas of having a mental health
disorder, paucity of psychiatrist and resources supporting mental health, the
direct and indirect costs of depression are expected to rise 26.
In Saudi Arabian health care system in general and primary care settings in
particular, data regarding cost of treatment of depression are rare to find. No
Saudi studies regarding the cost of treatment, lost productivity and/or
monetary benefit of screening for depression were found upon literature review.
United States Preventive Services Task Force
(USPSTF) has recommended screening elderly, adults and adolescents 12–18 years
of age for depression 4, 33, 34.
Ultra-short screening instrument, Patient Health Questionnaire (PHQ-2) asking
two simple questions about mood and anhedonia, is as effective as longer
screening instruments, such as the Beck Depression Inventory (BDI) or Zung
Depression Scale (ZDS) 32, 35, 36.
PHQ-9 is one of the most common instruments used for depression screening, and
it is increasingly being used for confirmation of a positive PHQ-2 result. The
PHQ-9 is valid, takes two to five minutes to complete 4, 37, 38.
1.6 Acknowledgements:
I would like to express
appreciation and great thanks to my colleagues at faculty of public health and
tropical medicine in jazan university and special thanks to our students in
health education and promotion program for their efforts in data collection
process.
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