ORIGINAL ARTICLE RISK FACTORS AND PREVALENCE OF Nauman Arif Jadoon *, Waqar Munir **, Zeshan Sharif Choudhry **, Rehan Yaqoob **, Muhammad Asif Shehzad **, Irfan Bashir **, Wasim Shehzad Rao **, Ali Raza ***, Kamran Siddiqui **, Muhammad Zubair *, Muhammad Fahad Arshad **. ABSTRACT OBJECTIVE: The objective of this study was to determine the prevalence of anxiety and depression in urban population of Multan and identify the related risk factors. STUDY DESIGN: Cross Sectional Study. PLACE & DURATION OF STUDY: Study was conducted at Nishtar medical College, Multan during 2008. METHODS: A predesigned questionnaire was administered to a sample of 444 people selected through random community sampling. The questionnaire used was Aga Khan University Anxiety and Depression scale (AKUADS) with a cutoff score of 19. The study was carried out in accordance with the ethical principles laid out in Declaration of Helsinki. Data was analyzed using SPSS v. 16. RESULTS: With a response rate of 90.54%, 402 people participated in the study. The mean age of study population was 29.58 ± 11.74 years. Using cutoff score of 19 on AKUADS, the prevalence of anxiety and depression was found out to be 41.04%. The factors associated with anxiety and depression were age more than 30 years (OR=1.94, 95%CI=1.28-2.93, p=0.001), level of education (OR=2.46, 95%CI=0.89-6.79, p=0.001), total family income (OR=0.28, 95%CI=10.13-0.60, p=) and occupation (OR=5.51, 95%CI=2.13-14.27, p=). It was seen that gender and marital status do not significantly affect the prevalence of anxiety and depression. CONCLUSION: The study shows that there is high prevalence of anxiety and depression in urban population of Multan. Community mental health programs should be developed and implemented to decrease the morbidity associated with psychiatric disorders. KEYWORDS: Epidemiology, Psychiatric disorders, Anxiety, Depression, Risk Factors. INTRODUCTION: Anxiety is a vague feeling of apprehension, worry, uneasiness, or dread, the source of which is often non-specific or unknown to the individual while a depressive disorder is an illness that involves the body, mood and thoughts. It affects the way a person eats and sleeps, the way one feels about oneself and the way one thinks about things. * IV Year M.B., B.S. ** V Year M.B., B.S. Nishtar Medical College, Multan *** House Officer, Nishtar Hospital Multan. Correspondence: Nauman Arif Jadoon (IV) year MBBS Nishtar Medical College, Multan dr.naumanjadoon@gmail.com Although prevalence of depression varies considerably across the globe, the most common symptoms of depression are depressed mood, insomnia and fatigue. Both anxiety and depression are divided into various subtypes. Patients with co-morbid anxiety and depressive disorder experience more severe symptoms, take longer time to recover, use more healthcare resources and have poorer outcome than do those with a single disorder 1. Anxiety and depressive disorders are common in general population. They are prevalent in all regions of the world 2. These disorders constitute a substantial proportion of the global burden of disease, and are projected to form the second most common cause of morbidity by 2020 3. 14 Nishtar Medical Journal Vol 1, No 2 April June 2009
These disorders exert financial burden on economy and are more important in developing countries where the amount of gross domestic product spent on health services is very low 4. Pakistan has a population of 165 million making it the sixth most populous country of the world and is projected to become the fourth most populous country by 2050 5. Psychiatric morbidity in the country is on the rise in the wake of growing insecurity, terrorism, political instability, economic problems, food shortage, global economic slowdown, growing unemployment and other problems. There is a need to determine the prevalence of anxiety and depressive disorder under the present circumstances so that preventive policies can be formulated. The objective of our study was to determine the prevalence of anxiety and depression in Multan, one of the major urban centers in Pakistan. We also wished to find out the relationship of anxiety and depression with socio-demographic characteristics. Such studies are useful in assessing needs of population, prevalence and associated risk factors of morbidity and in monitoring health of population and trends 6. PARTICIPANTS & METHODS: This cross-sectional study was carried out in 2008 in Multan. Multan is divided into four towns for administrative purposes. Households were randomly chosen from all the four towns of Multan in equal number. The study was conducted in compliance with ethical principles outlined in Helsinki Declaration. Verbal consent was taken before administering the questionnaire. Confidentiality of the participants was ensured. We distributed the questionnaires which were collected on a later date. All the adults with age ranging from 18 to 65 years were included in the study. Sample size was calculated assuming prevalence rate of 50%, error of 5%, confidence level of 95% which turned out to be 385. This was increased by 15% to 444 to account for incomplete and unreturned questionnaires. The instrument used to assess the anxiety and depression levels was, Aga Khan University Anxiety and Depression Scale (AKUADS) 7,8. At a cut off score of 19 points AKUADS has specificity of 81%, sensitivity of 74%, a positive predictive value of 63%, and negative predictive value of 88% 7, which is higher than other available scales like the self-reporting questionnaire (SRQ) 9,10. Several questions regarding socio-demographic characteristics were added to the questionnaire. If the participants could not read the questionnaire, there forms were filled by family members or investigators who served as interviewer. Data were analyzed using Statistical Package for Social Sciences 16 (SPSS, Inc., Chicago, IL, USA). Chi-square test was employed to look for associations between prevalence of psychiatric morbidity and gender, marital status, household income, occupation and other sociodemographic variables. Results were recorded as frequencies and means ± standard deviations (SD). Univariate logistical regression model was used to estimate the odds ratio and their confidence intervals. For all purposes, a p value of < 0.05 was considered as the level of significance. RESULTS: With a response rate of 90.54%, 402 people participated in the study. The mean age of study participants was 29.58±11.74 years. Using a cutoff score of 19 on AKUADS, it was found that 41.04% of the participants were suffering from clinically significant anxiety and depression. Sociodemographic characteristics of participants are given in table 1. Association of different variables with anxiety and depression are given Nishtar Medical Journal Vol 1, No 2 April June 2009 15
in table 2. Sociodemographic factors associated with increased prevalence of anxiety and depressive disorders were found to be age (more than 30 years), education, (low level), household income (low) and unemployment status (unemployed). Table 1: Sociodemographic Profile of Study Population (n=402) Variables Respondents % Age <30 Years 249 61.94 >30 Years 153 38.06 Gender Male 237 58.96 Female 165 41.04 Marital status Married 229 56.97 Unmarried 173 43.03 Illiterate 120 29.86 Education Matric 63 15.67 Intermediate 102 25.37 Graduate & Above 17 29.10 Up to Rs.10,000 220 54.72 Total Family Income (Monthly) Rs.10,000-Rs.20,000 75 18.65 Rs.20,000-Rs.40,000 64 15.92 Above Rs.40,000 43 10.70 Employment Employed 257 63.93 Unemployed 145 36.06 Professional 30 7.46 Skilled Work 44 10.95 Office Work 35 8.70 Occupation Sales 83 20.65 Agriculture 18 4.48 Unskilled Work 47 11.69 Unemployed 145 36.07 No significant association was found for gender and marital status. Professionals were found to be less anxious and depressed than other occupational groups. DISCUSSION: This is the first study from southern Punjab reporting prevalence of psychiatric illness at a community level to the best of our knowledge. The prevalence of anxiety and depression among the study population in our study is 41.04% which is comparable to the mean overall prevalence of 34% in community population reported earlier 11. The prevalence rates from our study are slightly higher than those reported in the systemic review 11. A recent study from NWFP found even higher prevalence rates of 65% in women and 45% in men 12. Another study has reported comparable prevalence rates of 35.7% in Karachi, 43.9% in Quetta and 53.4% in Lahore 13. Possible reasons for our findings can be exposure of population to economic uncertainty, political instability, terrorism, violence and regional conflicts. These have been found to be risk factors for psychiatric disorders 14. Analysis of factors associated with prevalence of anxiety and depression in our study from urban areas of Multan revealed that age, education, total family income and occupation are significantly associated with presence of psychiatric illness. Increasing age was found to be positively associated with risk of anxiety and depression, higher age group being more vulnerable to developing psychological morbidity. This is in accordance with some of studies reported earlier from other areas of Pakistan 15,16. In our study higher level of 16 Nishtar Medical Journal Vol 1, No 2 April June 2009
education was found to have negative association with depression which is the same as reported in earlier studies 17,19. Employment status had a significant effect on the prevalence of anxiety and depression. Unemployed people were found to be 5 times more likely to be depressed. This maybe because we included housewives in this group and females are more prone to psychiatric distress. Variables Age Gender Marital status Education Income Employment Occupation Table 2: Factors Associated With Risk of Anxiety and Depression Disorder Anxiety & Depression Present Absent Odds Ratio 95%CI p value <30 Years 87 162 1 - >30 Years 78 75 1.94 1.28-2.93 Male 91 146 1 - Female 74 91 1.30 0.87-1.95 Married 95 134 1 - Unmarried 70 103 0.96 0.64-1.43 Illiterate 52 68 1 Secondary 35 28 1.63 0.88-3.02 Intermediate 41 61 0.88 0.51-1.50 Graduate & Above 37 80 0.60 0.35-1.02 Up to Rs.10,000 114 106 1 - Rs.10,000-Rs.20,000 19 56 0.32 0.18-0.57 Rs.20,000-Rs.40,000 22 42 0.49 0.27-0.88 Above Rs.40,000 10 33 0.28 0.13-0.60 Employed 81 176 1 Unemployed 84 61 2.99 1.97-4.54 Professional 6 24 1 - Skilled Work 12 32 1.5 0.49-4.58 Office Work 10 25 1.6 0.50-5.09 Sales 31 52 2.38 0.88-6.47 Agriculture 6 12 2.0 0.53-7.54 Unskilled Work 16 31 2.06 0.70-6.06 Unemployed 84 61 5.51 2.13-14.27 0.001 0.202 0.842 0.001 However, difference in this case far exceeds the gender difference in prevalence rates. With respect to occupation category, we found that professionals were less likely than people in other groups to be depressed. Limitations of the study include use of self administered questionnaire to determine the presence of anxiety and depression rather than the more accurate diagnostic interview and lack of study of additional factors which may affect the psychiatric health of study population. Furthermore, the study does not identify the reasons for increase susceptibility of certain groups to psychiatric illness. CONCLUSION: The results suggest that anxiety and depression is highly prevalent among people living in urban areas of Multan. Community mental health programs should be developed and implemented to decrease the morbidity associated with psychiatric disorders. REFERENCES: 1. Hirschfeld R.M.A. Comorbidity of major depression and anxiety disorders: recognition and management in primary care. Primary Care Companion J Clin Psychiatry 2001: 3; 244-254. 2. Institute of Medicine. Neurological, psychiatric, and developmental disorders: meeting the challenge in the developing world. Washington, DC: National Academy Press, 2001. Nishtar Medical Journal Vol 1, No 2 April June 2009 17
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