Depression is a common, chronic, relapsing disorder, associated worldwide with substantial morbidity and excessive use of health care services.12 In addition, depression is the commonest disease leading tragically to suicide. It is estimated that between 11-17% of the severely depressed patients ultimately commit suicide.3–5
Depression is frequently misdiagnosed or even missed completely; which, ultimately, results in the underestimation of published prevalence rates.67 In reality, the scope of depressive problems is still immense, for up to 10% of patients in primary care settings have depression.8 The rate of developing depression is thought to be as high as 16-25%.9–13 However, it coexists with anxiety disorders, eating disorders and substance abuse.3 Higher estimates of depressive disorders were reported in the younger age group,1310 in comparison with low rates in the elderly.14–17 These disorders are thought to be more among females, the divorced or separated, and in lower socioeconomic groups.1118–20
The aim of the present preliminary study was to determine the frequency and pattern of depressive disorders in a Saudi teaching hospital; perhaps for the first time.
The study included all the new patients attending the Psychiatric Outpatient Department Clinics (total sample of 632) in King Fahd Hospital of the University (KFHU) during a period of two years from April 2000 to March 2002. The patients were seen, assessed and investigated by the Author and other Consultant Psychiatrists in the department. The Psychiatric Assessment was carried out by using a semi-structured psychiatric interview and a standard mental state examination.21 Special attention was paid to socio-demographic aspects of the history of the patient, such as the age, sex, nationality, marital status and occupation. The intelligence of the patients was assessed only clinically (general information, school and work records), and personality was assessed only in descriptive terms. No formal testing or inventories were carried out due to technical difficulties. The psychiatric diagnoses of the patients were made along the lines cited in the ICD-10 Classification of Mental and Behavioral Disorders Clinical Descriptions and Diagnostic Guidelines.21
In addition, physical examination and basic investigations, e.g. blood tests, thyroid, liver and kidney function tests were done for all the patients. Further relevant investigations such as EEG, Brain scan, MRI, etc. were carried out only when an organic disease is suspected. There was a regular follow up of patients during the study period.
The total number of patients who attended the Psychiatric Outpatient Clinics during the study period was 632. Of those, 122 patients were diagnosed as suffering from depressive disorders giving a frequency of 19.3%.
A total of 105 patients (72%) were between the ages of 20 and 49 years (Table 1). Only 2 patients were below the age of 10, and 4 patients above 70 years of age. The mean age of the patients was 36 years, and the Standard Deviation was 14.76. Ninety two patients were female and 54 male; a ratio of 1.7:1; making the differences statistically significant (x2 = 18.75, p <0.00002).
One hundred and four patients were married, 37 patients single, three patients divorced and two patients widowed. One hundred and forty one patients were Saudis and only five patients were non-Saudis. Two of the latter were Arabs. With regards to employment, 104 patients were unemployed (66 housewives, 22 students, 16 unemployed); 13 had white collar jobs (seven teachers, one social worker, one nurse, one secretary, three retired). Seven were in the services (one policeman, four soldiers, two security guards), 11 employed in jobs unknown, four were professionals, four were low-paid workers (one housekeeper, one housemaid, one salesclerk and one transporter) and three were employers. All patients were of average intelligence and there was no significant deviation of the patient's personality from the normal.
Twenty-six patients (21.3%) were diagnosed with mild depression, 50 (41%) patients with moderate depression and 28 (19%) with severe depression. Thirteen (10.6%) patients were dysthymic; and 5 (3.42%) patients had recurrent depression. Depression was co-morbid in 24 (19.6%) patients (Table 2).
The frequency of depressive disorders in the present study was 19.3%. Similar figures were reported in studies abroad and frequency rates for developing depressive disorders ranged between 16-25% in the majority of reliable studies.9–1322 Even higher rates were reported, especially in primary care settings. El-Rufaie's study in the same area but in different setting reported a prevalence rate of 55%.23 Abiodun in Nigeria reported 51.7% of depressive illness,24 and Ghubash in Dubai reported a rate of 13.7% among women only.25 Lower rates for depressive disorders were also reported elsewhere.2627
Severe depression with or without psychotic symptoms in the present study constituted 20% of all depressive disorders compared with 10% reported by Katon in 1992,8 16% by Chichester in 199210 and 17% by Kessler in 1994.12 These wide differences in frequency of depression are probably due to methodological differences in study designs.
The frequency of dysthymia in the present study was 9%, compared to 6.4% reported by Kessler12 and 3% in the Epidemiological Catchment Area (ECA) study in the United States of America.13 Recurrent depression constituted 3.4% in our study, compared with 5% in the Zurich study,10 these differences in the results can be explained on the basis of differences in the methods and study design.
Depression is more prevalent in the age group of 20-49 years, and the mean age of onset of unipolar depression in Epidemiological Catchment Area Study (ECA) was 27 years.13 In our study, 72% of the patients were between the same age range but the mean age of the patients was 36. It seems that our patients present to the psychiatric clinic rather late, compared with the patients in the ECA study.
In the present study, females were significantly more than males, in the ratio of 1.7:1. This is in accord with all studies. Thus, in the ECA study13 a ratio of 2:1 is reported, while Gabroon et al reported a 3.3:119 and a ratio of 1.63:1 was reported in Zhonghua's study.28
Depressive disorders are consistently increased in women across different cultures. The reasons for increased rates among women is not known, but the fact that women would more readily complain of symptoms than men, in addition to misdiagnosis and co-morbidity with drug abuse in men, might play a part.
The notion that depressive disorders are more common among the divorced13 was not substantiated in the present study; the majority of patients in our study (104) were married. It seems that marriage did not give much of a defense against developing depression.
Depressive disorders are more common among the unemployed but this was not clearly associated to the socio-economic indices.1329 In our study, 100 patients were formally unemployed; two-third of these were housewives and one-fifth were students.
The Saudi pattern of depressive disorders seems to have much in common with the characteristics of the disease elsewhere. Depression is a widespread disorder and remains costly in relation to human and financial resources. More attention should be given to its diagnosis and management, and cooperation and the possible integration of various medical and social services would go a long way in dealing with the problem.
I am indebted to Professor Hassan B. Abdel Hafeiz for his valuable advice in the manuscript. I am also thankful to all my colleagues in the Department of Psychiatry.
1. Simon GE, VonKorff M, Ba W. Health care costs of primary care patients with recognized depression Arch Gen Psychiatry. 1995;52:850–6
2. Unutzer J, Patick DL, Simon G, et al Depressive symptoms and the cost of health services in HMO patients aged 65 years and older: a 4-year prospective study JAMA. 1997;277:1618–23
3. . American Psychiatric Association (US) Diagnostic and Statistical Manual of Mental Disorders. 1994 Washington DC American Psychiatric Association
4. Black D, Winokur G, Hasralla A. Suicide in subtypes of major affective disorders Arch Gen Psychiatry. 1987;44:878–80
5. Coryell W, Winokur GPaykell ES. Course and Outcome Handbook of Affective Disorders. 1992 Edinburgh Churchill Livingstone:80–108
6. Rockville MDDepression Guideline Panel. . Depression in Primary Care: Volume 1 Treatment of Major Depression. Clinical Practice Guideline, Number 5. 1993 US Department of Health and Human Services, Public Health Service, Agency for Health Care policy and Research. AHCPR Publication No 93-0551
7. Hirschfeld RMA, Keller MB, Panico S, et al The National Depressive and Manic-Depressive Association consensus statement on the under treatment of depression JAMA. 1997;277:333–40
8. Katon W, Schulberg H. Epidemiology of depression in primary care Gen Hosp Psychiatry. 1992;14:237–47
9. Kessler RC, McGonagle KA, Zhao S, et al Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey Arch Gen Psychiatry. 1994;51:8–19
10. Chichester Wiley. How recurrent and predictable in depressive illness: in long-term treatment of depression Zurich studies. 1992:1–13
11. Regier DA, Boyd GH, Burke JD, et al One month prevalence of mental disorders in United States Arch Gen Psychiatry. 1988;45:977–86
12. Kessler RC, McGonagle KA, Zhao S, et al Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey Arch Gen Psychiatry. 1994;51:8–20
13. Smitt AL, Weissman MMPaykel ES. Epidemiology Handbook of Affective Disorders. 1992 Edinburgh Churchill Livingstone:111–29
14. Weissman MM. Increasing rates of depression Journal of the American Medical Association. 1989;261:2229–35
15. Jorm AF, Mackinnon A. The prevalence of depressive disorders and the distribution of depressive symptoms in later life: a survey using draft ICD-10 and DSM-III-R Psych Med. 1993;23:719–29
16. Klerman GL, Lavori PW, Rice J, et al Birth cohort trends in rates of major depressive disorder among relatives of patients with affective disorder Arch Gen Psychiatry. 1985;42:689–95
17. Bachar JR, Hughes DC. Major depression with melancholia: a comparison of middle-aged and elderly adults Journal of the Geriatrics Society. 1987;35:927–32
18. Boyd JH, Weissman MMPaykel ES. Epidemiology Handbook of Affective Disorders. 1982 Edinburgh Churchill Livingstone:109–15
19. Gabarron HE, Vidal RJ, Haro AJ, et al Prevalence and detection of depressive disorders in primary care Aten Primaria. 2002;29(6):329–37
20. Marcotte DE, Wilcox-Gok V, Redmon PD. Prevalence and patterns of major depressive disorder in the United States labor force J Ment Health Policy Econ. 1999;2(3):123–31
21. . World Health Organization The ICD-10 Classification of Mental and Behavioral Disorders Clinical descriptions and diagnostic guidelines. 1992 Geneva WHO
22. Hollified M, Katon W, Morojele N. Anxiety and depression in an outpatient clinic in Lesontho, Africa Int J Psychiatry Med. 1994;24(2):179–88
23. El-Rufaie OE, Absood GH. Minor psychiatric morbidity in primary health care: prevalence, nature and severity Int J Soc Psychiatry. 1993;39(3):159–66
24. Abiodun OA. A study of mental morbidity among primary care patients in Nigeria Compr Psychiatry. 1994;34(1):10–3
25. Ghubash R, Hamdi E, Bebbington PI. Prevalence and socio-demographic correlates Soc Psychiatry Psychiatr Epidemiol. 1992;27(2):53–61
26. Chocron BL, Vilalta FJ, Legazpi RI, et al Prevalence of psychopathology at a primary care center Aten Primaria. 1995;16(10):586–93
27. Lehtinen V, Joukamaa M, Lahtela K, et al Prevalence of mental disorders among adults in Finland: basic results from the Mini Finland Health Survey Acta Psychiatr Scand. 1990;81(5):418–25
28. Xiao Z, Yan H, Xiao S. Depressive disorders among outpatients in general hospitals Zhonghua Yi Xue Za Zhi. 1999;79(5):239–31
29. Ghubash R, Hamdi E, Bebbington P. The Dubai Community Psychiatric Survey: Prevalence and socio-demographic correlates Soc Psychiatry Psychiatr Epidemiol. 1992;27(2):53–61