Samya Flamerzi,
Consultant Family Physician - PHC - Qatar
Nada Al-Emadi,
Specialist Family Physician - PHC -Qatar
Mohamed Ghaith Al- Kuwari
Consultant Community Medicine - PHC -Qatar
Issa Mousa Ghanim,
Specialist Family Physician - PHC -Qatar
Abdelmajeed Ahmad,
Consultant Family Physcian- PHC -Qatar

Correspondence:
Dr. Samya Flamerzi
Primary Health Care Department
P O Box 3050
Doha -Qatar

Depression is a major public global health problem and a leading predictor of functional disability and mortality.(1) It is ranked fourth among the ten leading causes of the total worldwide disease burden, measured in Disability Adjusted Life Years (DALY). The WHO predicted that by the year 2020 depression would be the second most important cause of disability after ischemic heart disease worldwide, accounting for 5.7% of the total DALY, compared to 2.6% for HIV. Furthermore, depression is expected to become the number one cause of disease burden among females in developing countries. In addition to being a major factor in disability, depression increases the risk of suicide and mortality.(1-3) It is estimated that 60% of all suicides are attributable to depression. (3-4)

According to the U.S. Preventive Services estimate Task Force (USPSTF), the prevalence of major depression in the primary care setting, ranges from 5 to 9% among adults, and up to 50% of depressed patients are not recognized. Other disabling depressive illnesses include dysthymia (a chronic low-grade depression) and minor depression (an episodic, less severe illness). These two illnesses are as common as major depression in primary care settings. (5)

While guidelines encourage PHC physicians to diagnose and treat their depressed patients, rates of detection and treatment in PHC are still sub-optimal.(1) A review of published studies suggests that PHC physicians fail to detect depression, which remains undiagnosed in one third to one half of cases.(6)

Recognizing depression in patients in the primary care setting may be particularly challenging because patients, especially men, rarely spontaneously describe emotional difficulties. On the contrary, patients with depression who present to a primary care physician often describe somatic symptoms such as fatigue, sleep problems, pain, loss of interest in sexual activity, or multiple, persistent vague symptoms.(6)

Brief, self-administered questionnaires have been recommended to be used in depression case-finding and follow-up in the primary care setting. The Patient Health Questionnaire (PHQ-9) has become one of the most frequently used self-reporting depression scales, because of its diagnostic validity, brevity, and ease of scoring, of the 9-item depression module form. (7) The Arabic version of PHQ has been validated and tested in primary care settings in Arab countries.(8)

As we do not know the prevalence of depression based on population based survey, this study was designed to estimate the prevalence of depression among people who attend primary health centers in Qatar, to evaluate the severity of depressive symptoms and to identify determinants of depression.

This cross-sectional study was approved by medical research committee at Hamad Medical Corporation. It was conducted during the period of August-September 2008 in four randomly selected primary health care centers, - two rural and two urban health centers. A total of 320 adult subjects were selected by using systematic random techniques by taking every tenth patient according to their order of attendance at the reception desk. Verbal consent was obtained from each participant who completed the questionnaire, supervised by an experienced nurse to assist the patients.

Both Arabic and English versions of the Questionnaire were used to collect socio-demographic data, which included questions about the socio-demographic characters such as age, gender, nationality, marital status, number of children if any, housing, income, occupation, education level, period of stay in Qatar, chronic diseases such as diabetes, hypertension, coronary artery diseases, others.

For screening for depressive symptoms, the Patient Health Questionnaire (PHQ-9) which is a validated screening tool to diagnose depression was used. It consists of nine questions based on the nine DSM-IV criteria for diagnosis of depression (Depressive syndromes are defined in DSM-IV, manifest with at least five of the following nine symptoms: depressed mood, change in psychomotor activity, loss of interest/pleasure, loss of energy, change in sleep, trouble concentrating, change in appetite or weight, thoughts of worthlessness or guilt, thoughts about death or suicide). Each of the questions asks patients to select the frequency of the depressive symptoms that they experienced in the two weeks before the survey's administration. Scores for each item range from 0 which means no symptoms at all to 3 (depressive symptoms nearly every day).

The final score was calculated, with scores between 10 and 14 indicative of a moderate level of depressive symptoms, scores between 15 and 19 indicate moderately severe major depression,
and scores 20 and above indicate severe major depression. Scores were calculated according to Table 1.

Table (1):-Diagnostic categories for depression according to the nine-item patient health questionnaire (PHQ-9) and treatment recommendations

Moderate depressive symptoms, moderately severe major depression and sever major depression were considered to be significant depression.

Analysis was carried out addressing the PHQ-9 outcome measures. All the information gathered was received before data entry by manual revision of the data. A Master sheet was prepared from the collected data.

Data was coded and entered into the statistical package of social sciences (SPSS) - 12 which was used for the analysis of the results. Frequency measures and bivariate statistical analysis such as chi square test, and Fischer exact test were performed. Level of significance selected for this study was (0.05), a confidence level of 95%.

Out of 320 patients selected, 306 have responded to questionnaires making the response rate of 95.6%. Table 2 shows that 175 (57.2%) were females, 102 (33.4%) participants were Qatari. In terms of age group, 152 (49.7%) participants were 18 years - 34 years, and 134 (43.8 %) were between 35 - 54 years, where 20 (6.5%) individuals were above 55 years. Married participants form 63.7% of the sample, singles account for 28.1%, while divorced widowed were 4.6% and 3.6% respectively.

Table (2) distribution of the socio demographic characteristics of the studied group (n=306)

Regarding the level of education 149 (48.7%) had university degree or above, while 98 (32.0 %) had secondary degree, only 29 (9.5%) had primary school education, 30 (9.8%) had preparatory level. About 72.6% of the participates were employees, 3.6% were unemployed, house wives account for 16.2% of sample, while students and retired were 4.6% and 3.0 % respectively.

Regarding period of living in Qatar, 44.7% of the subjects were born in Qatar, 20.4% staying in Qatar from 1 - 5 years, 12.2% stayed from 5 - 10 years, and 22.7% stayed more than 10 years in Qatar.

In terms of presence of other chronic diseases such as diabetes mellitus, hypertension, coronary artery disease and bronchial asthma, 126 (41.2%) of respondents had one or more chronic diseases only 18 (5.9%) individuals had previous psychiatric illnesses (anxiety and or depression). In terms of unhealthy lifestyle among the participants, 16.3% use tobacco 2.6% use alcohol.

In the social context, 242 (79.3%) of the respondents of the screened participants were living away from their families. And in terms of presence of conflict, 63 (20.6%) of individuals were found to have marital conflicts, while work conflicts present in 18.6% of our sample.

Of the 306 participants we found that 85 (27.8%) screened positive for clinically significant depressive symptoms (PHQ-9 score of 10 or higher), while 24.8% had minimal depressive symptoms (PHQ-9 score less than 10) as shown in Figure -1. Of those who have significant symptoms 47 (15.4%) had PHQ-9 scores between 10 and 14 (moderate depressive symptoms), 28 (9.2%) had PHQ-9 scores between 15 and 19 (moderately severe major depression) and 10(3.3%) had PHQ-9 scores of 20 and above (severe major depression).

Figure (1) percentage of level of depressive symptoms according to PHQ-9 scores.

Table (3) The distribution of risk factors of depression disorders in the study

The influence of socio-demographic characteristics on the prevalence of depressive disorders is shown in Table 3. The highest frequency of depression was among young age group (18-34) which accounts for 61.2%, followed by the (35-54) age group (32.9%), and the least was old age group > 55 years 5.9%. Persons with secondary, university and above studies had the higher frequency of depression 41.2%, and 33.0% respectively (P=0.029), while persons with primary education level had less frequency (9.4%).

Table (4) the distribution of depression cases according to the demographic variables.

Table-4 shows unmarried subjects (singles, divorced and widowed) were more prone to have clinically significant depression (53.0%). Persons who were living in Qatar since birth had the highest frequency of depression (59.5%) while those who stayed >10 years had the lowest frequency 11.9%.

For other demographics such as nationality, gender, occupation, income and number of children, they were not significant.

Although there was a strong relationship with previous history of psychiatric illnesses e.g. anxiety and or depression (P=0.00), as shown in Table-5, there was no significant relationship between chronic disease and depression.

We found a statistically significant relationship between marital problems, work conflict, smoking, alcohol drinking and presence of significant depressive symptoms (P=0.05).