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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
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Email: dr.zbaig@hotmail.com
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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%).
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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.
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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].
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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-eIqbal,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-eFaisal 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
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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.
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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. .
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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].
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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 AttentionDeficit/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.
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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
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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
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5. Surveillance of depression in Karachi, Pakistan Rabia Bushra, M.Phil.B.Pharm, HumaAli,
M.Phil.B.Pharm. Available at
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Revise the Mental Health Policy. Amin A. Muhammad Gadit, Gerry Mugford [PubMed]
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systematic review Ilyas Mirza, s, Rachel Jenkins. BMJ 2004; 328:794
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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
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of Karachi. J Coll Physicians Sur Pak 2000; 10:4-6.
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between parent role quality and psychological distress: A study of men and women in dualearner couples. Journal of Family Issues, 15, 229-252.
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17. Krishnan KRR, Taylor WD, McQuoid DR, MacFall JR, Payne ME, Provenzale JM, Steffens
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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/p20md01.html. Date accessed: 22/4/2012
20. Understanding Depression by Betty Burrows, PhD. Available at:
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21. Article on different types of depression. Available at: http://www.all-on-depressionhelp.com/different-types-of-depression.html
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Table 1: Demographic characteristics of women
Variables
Marital status
Married
Depression
No depression
Total(n=454)
Frequency(n) Percentage(%) frequency Percentage(%)
108
36.2
190
65.7
Single
Divorced
Widow
Income groups
33
16
19
37.9
45.7
55.9
54
19
15
62
54.3
44
0-20000
20001-40000
40001-60000
60001-80000
80001-100000
100001>100001
49
25
30
20
35
17
46.6
34.7
42.8
30.3
40.2
56
47
40
46
52
31.5
37
53.3
65.3
57.1
69.6
59.8
68.5
38.8
35.2
40
39.8
58
29
49
70
63
53
13
22
27.2
8
Age groups
18-24
25-31
32-38
39-45
46-52
53-59
60-66
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31
38
42
35
18
9
3
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61.3
64.8
38
60.2
41.9
70.9
72.7
298
87
35
34
105
72
70
66
87
54
80
108
105
88
31
31
11
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Table 2: shows the type of depression in working and household women
Type of
depression
Depressive
disorder
Major
depressive
disorder
Other
depressive
disorder
No
depressive
disorder
Household Percentage(%) Working
women(n)
women (n)
22
9.6
31
Percentage(%)
22
14.5
40
9.7
33
13.7
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143
17.6
27
11.9
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
type of depression
depressive disorder
major depressive disorder
other depressive disorder
no depressive disorder
12%
12%
61%
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15%
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Table 3: Frequency of problems faced by women:
Problems
Family issues
Yes
No
Financial problems
Yes
No
Work load
Yes
No
Peer pressure
Yes
No
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Household
(n=227)
Percentage
(%)
Working(n=227)
Percentage(%)
104
111
45.8
48.9
123
116
54
51.1
57
170
25.1
74.9
90
137
39.6
60.3
84
143
37
62.9
98
129
43.1
56.8
83
144
36.5
63.4
67
160
29.5
70.48
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Table 4: Table showing the response of the women to the Patient Health Questionnaire-99
Variables
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
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Frequency(n=454)
Frequency(n)
Percentage (%)
180
147
91
36
39.6
32.3
20
7.9
185
150
84
35
40.7
33
18.5
7.7
165
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
181
89
19
39.8
19.6
4.2
154
174
85
41
33.9
38.3
18.7
9
138
159
105
52
30.4
35
23.1
11.5
158
160
96
40
34.8
35.2
21.1
8.8
148
154
116
36
32.5
33.9
25.5
7.9
159
170
105
20
35
37.4
23.1
4.4
187
141
93
41.2
31.1
20.5
358
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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
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Nearly every day
33
7.3
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
108
194
115
37
23.8
42.7
25.3
8.15
359
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