THE PREVALENCE OF DEPRESSIVE SYMPTOMS AND POTENTIAL RISK FACTORS THAT MAY CAUSE DEPRESSION AMONG ADULT WOMEN IN SELANGOR

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1 ORIGINAL PAPER THE PREVALENCE OF DEPRESSIVE SYMPTOMS AND POTENTIAL RISK FACTORS THAT MAY CAUSE DEPRESSION AMONG ADULT WOMEN IN SELANGOR Sherina MS*, Rampal L*, Azhar MZ** *Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Malaysia, ** Department of Psychiatry, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Malaysia ABSTRACT Introduction: Women are exposed to stress such as working full time while still being responsible for the family and house. Objective: The objective of this study was to determine the prevalence of depressive symptoms among adult women in Selangor, and to determine the potential risk factors associated with depression. Method: A community based cross sectional study was conducted in all districts of Selangor state, Malaysia in July Multi stage stratified proportionate to size sampling method was used to collect data. The Patient Health Questionnaire (PHQ-9) was used to determine the presence or absence of depressive symptoms among the respondents. All respondents aged 20 to 59 years old in the selected households were interviewed. Results: Out of 1032 women, 972 agreed to participate in this study, giving a response rate of 94.2%. The mean age of the respondents was ± Majority were Malays (54.9%), married (83.8%) and had secondary education (54.5%). The results showed that the prevalence of depressive symptoms was 8.3% in Selangor. Race, religion, education level, history of having a miscarriage within the last 6 months and history of difficulty in getting pregnant were significantly associated with depressive symptoms (p<0.05). Women with history of a miscarriage within the last 6 months and absence of formal education were potential risk factors for depressive symptoms (OR, CI = ( ), p<0.01 and OR, CI = ( ), p < 0.01). Conclusion: Depressive symptoms among adult women in Selangor was 8.3% and was associated with race, religion, education, history of miscarriage and difficulty in getting pregnant. The main potential risk factors were having a miscarriage within the last 6 months and absence of formal education. Keywords: Depressive symptoms, Prevalence and Risk Factors, Selangor Women

2 Introduction The life expectancies of women in both developed and developing countries are increasing with improved health services and living conditions. The life expectancy of Malaysian women was 75.2 years in 2001 compared to 65.6 years in ,2 Today, women are exposed to large amounts of stress. 3 The stress of taking care of young children, having an unstable marriage, or working full time while still being responsible for the house and family. 3 Women are usually the primary caretakers for both young and old, often under financial strain or outright poverty. Many women focus so much on caring for others that they do not attend to themselves. Their own well-being takes a distant second to the needs of others. All these affect the mental health status of women making them vulnerable to develop mental health problems, namely depression. 4 Poor mental health status is a major health problem that occurs more commonly in women. 5 Over the course of a lifetime, depression, which is a common mental health disorder occurs in approximately 20% of women compared to 10% of men. This statistic is the same regardless of country or race or economics. 5 Married women have higher rates of depression than unmarried women, with rates peaking during the childbearing years. Depression occurs most frequently in women years of age. Reasons why women are at increased risk for poor mental health status are biological factors such as hormonal changes and genetics, physiological factors such as body weight, and social factors such as stresses from work, family responsibilities and poverty. 6 Studies in Malaysia have shown that the prevalence of mental health problems, which consists mainly of depression are 7 higher in women than in men. However, not many studies have been done on mental health status of women despite women nowadays being very much exposed to stress. This study hopefully can provide information on the mental health status of women in Malaysia, as well as make recommendations for the improvement of mental health. The objective of this study was to determine the prevalence of depressive symptoms among adult women in Selangor, as well as to identify the potential risk factors that may cause depression. Method This community based cross sectional study was conducted in Selangor in July 2004, for a duration of 4 weeks. All districts were included. Multi stage stratified proportionate to size sampling method was used to select households in each district. All women aged years old in the selected households were included in this study and were contacted via home visit. This age group

3 was chosen so that only adult women were included in this study, and not children, adolescents and elderly. Non- Malaysian citizens were excluded from this study. A standardized pre-tested structured questionnaire was used by trained personnel to collect data from the respondents via face-to-face interview. The questionnaire consisted of 4 parts which consisted of questions on socio demography (age, ethnicity, religion, education level, occupation and monthly income), marriage profile, obstetrics and gynaecology history, and the Patient Health Questionnaire (PHQ-9) which was used to determine the presence or absence of depressive symptoms. The Patient Health Questionnaire (PHQ- 9) was developed by Drs. Robert L Spitzer, Janet BW Williams, Kurt Kroenke and colleagues. It was developed from the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (PRIME-MD PHQ). It is a self-report questionnaire and consists of 9 questions that identify depressive symptoms. The PHQ Depression Severity Index score is used to calculate for the presence of depressive symptoms. 8 The questionnaire was translated and validated in Bahasa Malaysia. Pretesting was done in another location not included in the study. Data was analyzed using the computer program Statistical Package for the Social Sciences (SPSS) version Descriptive statistics were used for all the variables studied. Pearson Chi-square, Odds ratio (OR) and 95% Confidence Interval (CI) were used to test the association and risk between each factor and depressive symptoms. Further analysis using multivariate logistic regression was also done to study the predictor outcome of the potential risk factors. Results Out of 1032 women, 972 agreed to participate in this study, giving a response rate of 94.2%. Age of the respondents ranged from years old. The mean age was 37.91±10.91 and median was (95% CI= ). The profile of the respondents is shown in Tables 1A and 1B. Table 1A: Profile of the respondents (Socio-demography) (n=972) Profile of the respondents n % Age years years years years Race Malay Chinese Indian Others Religion Islam Buddha Christian Hindu

4 Others Education level No formal education Primary education Secondary education Tertiary education Have you ever been married Yes No How old were you when first married Not married years years years years years Table 1B: Profile of the respondents (Obstetrics and Gynecology history) (n=972) Profile of the respondents n % Best describes of your menstrual periods - Periods are unchanged No periods because pregnant or recently gave birth - Periods have become irregular or changed in frequency - No periods for at least a year Having periods because taking hormone replacement therapy Have a serious problem with your mood during the week before your periods start Yes No (IF Yes : Do these problems go away after end of the periods?)(n=240) Yes No Given birth within the last 6 months Yes No Had a miscarriage within the last 6 months Yes No Having difficulty getting pregnant (For those who are married)(n=815) Yes No

5 Out of 972 respondents, 81 had depressive symptoms based on the PHQ- 9 scores, giving a prevalence of 8.3% among adult women aged 20 to 59 years old..in.. this..study. Table..2 shows. the association of depressive symptoms and socio demographic factors. Depressive symptoms were significantly associated with education level (p=0.036), race (p=0.004) and religion (p= 0.001) of the respondents. Table 2: Association between depressive symptoms and socio-demography among the respondents (n=972) Profile of the Depressive No depressive p value OR 95% CI respondents symptoms symptoms n(%) n(%) Age years 65(8.1) 734 (91.9) years 16(9.2) 157(90.8) Education level Formal education 72(7.9) 843(92.1) 0.036* No formal education 9(15.8) 48(84.2) Occupation Yes 35(9.0) 354(91.0) No 46(7.9) 537(92.1) Monthly salary < RM (7.4) 611(92.6) RM (10.3) 280(89.7) Race Malay 42(7.9) 492(92.1) 0.004* Chinese 7(3.6) 187(96.4) Indian 30(13.2) 197(86.8) Others 2(11.8) 15(88.2) Religion Islam 43(7.9) 504(92.1) 0.001* Buddha 5(3.0) 160(97.0) Christian 2(4.5) 42(95.5) Hindu 31(14.6) 181(85.4) Others 0(0.0) 4(100.0) * p<0.05=significant Respondents who had no formal education had significantly higher prevalence of depressive symptoms compared to respondents who had formal education (p=0.036). The prevalence of depressive symptoms were highest among the Indians (13.2%) followed by other races (11.8%), Malays (7.9%) and Chinese (3.6%). Further analysis found that the difference was significant between Malay vs Chinese (p=0.043), Malay vs Indian (p=0.021) and Chinese Vs Indian (p=0.001). The prevalence of depressive symptoms were

6 also highest among the Hindus (14.6%) followed by Muslims (7.9%), Christians (4.5%) and Buddhist (3.0%). Further analysis found that the difference was significant between Muslim vs Buddha (p=0.030), Muslim vs Hindu (p=0.005) and Buddha vs Hindu (p<0.001). Depressive symptoms were significantly associated with history of having a miscarriage within the last 6 months (p = 0.001) and difficulty in getting pregnant (p = 0.049). Other findings such as menstrual history and problems with mood (before and after menstrual periods) were not significant (p > 0.05). Further analysis using..multivariate logistic regression to study the association between depressive symptoms and selected associated factors found that history of having a miscarriage within the last 6 months and absence of formal education were potential risk factors for depressive symptoms among the respondents (Table 3). Table 3: Association between selected associated factors and depressive symptoms among respondents (multivariate logistic regression analysis) (n=972) Variables Regression Coefficient (β) OR (95% CI) p-value Constant Value Educational level ( ) *0.019 Formal education** No formal education History of miscarriage within last 6 months ( ) *0.002 Yes** No Difficulty in getting pregnant ( ) Yes** No Significant at p-value < 0.05*, Reference Category**, OR = Odds Ratio, CI = Confidence Interval Discussion This study found that the prevalence of depressive symptoms among adult women aged 20 to 59 years old was 8.3%. This finding is slightly lower compared to the study by Ialongo N et al who found that the prevalence of depression was about 11.4% among African-American adult women from years Depressive symptoms in this study were significantly associated with education level (p=0.036). The odd of having depressive symptoms was two times higher for women with no formal education compared to women who had formal education. Absence of formal education was also found to be a potential risk factor for depressive symptoms among women in this study.

7 This finding is supported by a study done by Berenson et al (2003) who found that women were at increased risk of moderate to severe symptoms of depression if they had not graduated 10 high school. Educational status determines the socio-economic level of a person and is significantly linked with occupational and financial status. Other studies in Malaysia have confirmed that low socio-economic status which is associated with no or low educational levels, unemployment, low income and financial problems are significantly associated with poor mental health status and depression. 11,12 This study also found that depressive symptoms was significantly associated with race (p = 0.004) and religion (p = 0.001), where the prevalence was highest among the Indians (13.2%) compared to other races, and Hindus (14.6%) compared to other religions. A study by Radziszewska et al (1996) among 3993 students in Los Angeles County and San Diego County found that ethnicity was significantly associated with depressive symptoms, with Asians having the highest prevalence of depressive symptoms, followed by Whites, Hispanics and African-Americans. The findings of this study highlighted the variation in the prevalence of mental disorders as a function of ethnicity and socioeconomic status. The data suggested that lower levels of socioeconomic status increase the risk for mental disorder. However, the link between SES and prevalence of mental disorder varies by the type of disorder and by ethnicity. 9 There was a significant association between depressive symptoms and history of having a miscarriage within the last 6 months in this study. The odds of having depressive symptoms was 5 times higher for women who had suffered a miscarriage within the last 6 months compared to women who did not suffer from any miscarriage. This was also found to be a potential risk factor for depressive symptoms among women in this study. Although there was also a significant association between depressive symptoms and difficulty of getting pregnant, further analysis did not find that infertility was a potential risk factor for depressive symptoms in this study. Studies have found that in women s childbearing life, problems such as infertility and miscarriage are fairly common. Both are stressful and can make some women more vulnerable to depression. 5 Swanson (2000) found that the women most at risk for depressive symptoms after miscarriage include women who do not conceive or give birth by 1 year after the loss. 13 Brier (1999) has described the risk of intense and long-lasting distress following miscarriage as higher if the woman strongly desired the pregnancy, waited a long time to conceive, or has no living children. 14 In conclusion, the findings of this study show that the prevalence of depressive symptoms among adult women aged 20 to 59 years old in Selangor was 8.3%. Factors found to be significantly associated with depressive symptoms were race, religion, education level, history of having a miscarriage within the last 6 months and difficulty in getting pregnant. Potential risk factors for depressive symptoms in these women were history of having a miscarriage within the last 6 months and the absence of formal education.

8 The lower prevalence of depressive symptoms in this study could be due to the higher socio-economic status and education level of the respondents in Selangor. Other studies in different states in Malaysia need to be done to obtain the overall prevalence of depressive symptoms among women in Malaysia. This result can then be compared to studies done in other countries. The characteristics of the groups with statistically higher prevalence of depressive symptoms also need to be further studied to assess their contribution to the burden of illness amongst these women. The main limitation of this study was that the questionnaire used (PHQ-9) had not been validated in the Malaysian setting. At present there are very limited questionnaires on depression which have been specifically validated in the Malaysian community. However, as a follow-up to this study, there is another study currently being conducted on the validation of depression questionnaires in government primary care clinics in Malaysia, and this includes the PHQ-9. As women are exposed to large amounts of stress due to the multiple roles they have to play as wife, mother daughter, employee or employer and so forth, factors associated with depressive symptoms among these women should be identified. It is important that depressive symptoms and its associated factors be identified early as depression can have severe effects on the sufferer s quality of life if left untreated for extended periods. Acknowledgement This study was conducted using the Fundamental Research Grant from The Research Management Centre of Universiti Putra Malaysia. References 1. Department of Statistics. Year Book of Statistics Malaysia Kuala Lumpur, Department of Statistics. Vital Statistics Time Series Peninsular Malaysia , Kuala Lumpur, Alexander JL. Quest for Timely Detection and Treatment of Women With Depression. Journal of Managed Care Pharmacy 2007;13(9):S3-S Subhash CB, Shashi KB. Depression in Women: Diagnostic and Treatment Considerations. American Academy of Family Physicians, Department of Mental Health and Substance Dependence, World Health Organization. Depression in Women (Part 2). Women s Mental Health: An Evidence Based Review, World Health Organization, Geneva, National Mental Health Association. Clinical Depression and Women. Alexandria, VA: National Mental Health Association, eet.women.cfm 7. Report of the Second National Health and Morbidity Survey Conference, Kuala Lumpur, Spitzer RL, Kroenke K, Williams JB. Validation and utility of self-report version of PRIME-MD: the PHQ

9 primary care study. JAMA 1999;282: Ialongo N, McCreary BK, Pearson JL, Koenig AL, Schmidt NB, Poduska J, Kellam SG. Major depressive disorder in population of urban, African- American young adults: prevalence, correlates, comorbidity and unmet mental health service need. J Affect Disorders 2004;79: Berenson AB, Breitkopf CR, Wu ZH. Reproductive Correlates of Depressive Symptoms Among Low- Income Minority Women. Obstet & Gynecol 2003; 102: Institute of Public Health (IPH). The...Second... National Health... and Morbidity Survey 2006 (NHMS II), Vol 16. Kuala Lumpur: Ministry of Health Malaysia, Wan Mohd Rushidi WM, Shakinah S, Mohd Jamil Y. Postpartum Depression: A Survey of the Incidence and Associated Risk Factors among Malay Women in Beris Kubor Besar, Bachok, Kelantan. Malaysian Journal Of Medical Sciences 2002; 9(1): Radziszewska B, Richardson JL, Clyde W, Flay BR. Parenting Style and Adolescent Depressive Symptoms, Smoking, and Academic Achievement: Ethnic, Gender, and SES Differences. J Behav Med 1996;19(3): Freda MC, Devine KS. The Lived Experience of Miscarriage After Infertility. MCM, Am J MCN 2003;28(1): Corresponding Address: Sherina Mohd Sidik, Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Malaysia. erina@putra.upm.edu.my