Depression among women in the South-Asian region: the underlying issues

Assessment of mental wellbeing of university students in Bangladesh using Goldberg's GHQ-12: A cross-sectional study

Background and Aims

The mental well-being of university students is a primary public health concern worldwide, including in Bangladesh. The objective of this study was to determine the prevalence of the overall mental health status among Bangladeshi university students. The study used larger and more diverse sample compared to previous studies, and also explored factors associated with the mental health well-being of those students.

Methods

Data were collected through an online questionnaire, utilizing the proportional allocation method, from students in various universities across Bangladesh. The sample included 2036 participants. The study applied Goldberg's General Health Questionnaire (GHQ-12) using the GHQ2+ threshold (i.e., having more than two symptoms). A binary outcome variable was created with two levels: "good mental health" and "poor mental health," to assess the mental health status of the university students. The explanatory variables were age, gender, academic year, type of university, and sources of personal expenses. Exploratory data analysis, association tests, and binary logistic regression models were used to identify factors influencing the outcome variable.

Results

A total of 55.9% of students (male: 52.6% and female: 62.8%) exhibited poor mental health status. Female students' mental health was found to be worse (odds ratio [OR]: 1.49, 95% confidence interval [CI]: 1.23-1.81) compared to that of males. Similarly, public university students displayed a worse mental health condition than their counterparts in private universities (OR: 1.29, 95% CI: 1.03-1.61).

Conclusion

The overall mental health of university students in Bangladesh is concerning. There is a pressing need for effective mental health policies and interventions to bolster the mental well-being of university students, with a specific focus on students from public universities and females.

The Stressor in Adolescence of Menstruation: Coping Strategies, Emotional Stress & Impacts on School Absences among Young Women in Nepal

Throughout the developing world, girls face hardships surrounding menstruation, often resulting in poor emotional wellbeing and missing school. Providing ways to keep girls in school will increase their educational and earning potentials, which will ultimately trickle down to improving the economic standing of nations in the next generation. Informed by the Transactional Model of Stress and Coping, this work evaluates the roles that cultural and school environments play in appraisals of menstruation as a major life stressor for adolescent females and the impacts of emotional stress on missing school. Using primary survey data from schools in Nepal, robust results are found to support the theoretical framework based on conditional mixed-process (CMP) estimation with fixed effects, utilizing multiple index building techniques. Strong cultural norms during menstruation appear to increase the probability of girls self-reporting emotional stress, while the presence of hygiene supporting infrastructure at schools reduces this outcome. Furthermore, there is strong support for the finding that the presence of emotional stress during menstruation increases the likelihood of not only missing school but also for an extended period of time. Our findings motivate increasing government policies to provide stronger hygiene infrastructure in schools to improve successful coping skills and attendance rates.

Prevalence and factors associated with depression among the mothers of school-going children in Dhaka city, Bangladesh: A multi stage sampling-based study

Background

Motherhood is associated with extra stress, and mothers of young children are particularly prone to developing depression and mental health problems.

Methodology

This analytical cross-sectional study was conducted in Dhaka city, Bangladesh, from June to December 2019. Mothers of school-going children were recruited through a multistage sampling technique. Dhaka city was divided into two divisions and then further subdivided into public and private sectors. Six schools were selected from each sector by using a simple random sampling technique. A list of class five to eight students were collected from each school by systematic random sampling. Data were collected through face-to-face interviews using semi-structured questionnaires. The rate of depressive symptoms was measured by the validated Zung Self-Rating Depression Scale (SDS).

Result

A total of 324 women participated in this study; the majority of the women (85.5%) were Muslim, 67.0% were housewives, and 53.1% had a girl child. Among the women, 15.4% had mild, 22.2% had moderate, and 20.1% had severe depression. Most of the child's behavioral and lifestyle factors were associated with the mother's depression. Adjusted analyses indicate that if a child is often unhappy, depressed, or tearful [(OR (95%CI = 22.27 (8.39-59.11)], gets nervous in new situations or easily loses confidence [(OR (95%CI) = 5.45 (2.96-10.00)], often lies or cheats [(OR (95%CI) = 8.93 (3.76-21.22)], gets afraid easily [(OR (95%CI) = 7.09 (3.79-13.24)], watches television for 3 h or more [(OR (95%CI) = 23.77 (6.46-87.48)] browses the internet for 3 h or more [(OR (95%CI = 7.37 (2.76-19.67)] were associated with mother's depression.

Conclusion

The study concludes that depression among the mothers of school-going children in Dhaka city of Bangladesh is high. Several lifestyles and behavioral factors of school-going children are significantly associated with the mothers' depression.

Prevalence of depression and its correlates among public university students in Bangladesh

This study aims to assess the prevalence of depression among public university students in Bangladesh, with a larger and more diverse sample than those included in previous studies. A cross-sectional study was conducted between April and September, 2018 at two public universities in Bangladesh. Data was collected on socio-demographic characteristics, lifestyle factors, history of depression, and symptoms of depression (9-item Patient Health Questionnaire). Multivariable logistic regression was applied to explore the independent relationships between depression and student characteristics. A total of 400 students participated in the survey. Mean age of the students was 22 (SD: 2.2) years. The prevalence of depression was 47.3% and higher in female than male students (50.7% vs. 43.6%). Results of the multivariate analysis showed that the odds were approximately 4.6 times higher for students who spent more than 6 hours per day on social media (OR:4.69, 95% CI: 1.94-11.30); more than 2 times higher among the students who had personal history of depression (OR: 3.51, 95% CI: 2.221-5.59). Male gender and having a smoking habit were both correlated with depressive symptoms (OR: 1.90; 95% CI:1.05-3.41) compared to the female students (OR:1.5; 95% CI:0.51-4.3). Nearly half of the students met the criteria for moderate to severe depression. Poor academic performance, use of social media and history of depression were the main factors associated with depressive symptoms. Given the high prevalence of depression in this student population, it is imperative to develop psychosocial interventions to better support students during this critical phase of life .

Dhat Syndrome—Revisiting the Phenomenology and Related Psychiatric Comorbidities

Background:

Dhat syndrome is a culture-bound syndrome found in men from India (and other South Asian countries), leading to a number of psychiatric problems.

Aim:

The study is aimed at studying the sociodemographic correlates of patients with Dhat syndrome and the occurrence of comorbid neurotic, stress-related, and somatic symptoms. It also aims to study the severity of comorbid anxiety and depressive symptoms.

Settings and Design:

This cross-sectional descriptive study was conducted in the Department of Psychiatry, Sri Ramachandra Medical College and Research Institute (Chennai).

Materials and Methods:

Fifty patients were recruited from consecutive outpatients attending the psychiatry department and assessment was carried out using a semi-structured pro forma, Dhat Syndrome Questionnaire, and Depression, Anxiety and Stress Scale.

Statistical Analysis:

The data collected here was analyzed using Statistical Package for Social Sciences (SPSS) version 20.

Results:

Most patients were found to be in the second decade of life and hailed from urban areas and lower socioeconomic status. Media and peer group were the source of information for three-fourths of the patients. A majority of the patients reported with somatic symptoms. Mild to moderate anxiety and depression scores were most commonly observed.

Conclusion:

The current study has illustrated that Dhat syndrome is associated with a lot of misinformation and leads to mild–moderate depression and anxiety symptoms, making its awareness and treatment extremely important.

'Silencing the self' and women's mental health problems: A narrative review

In the context of women's mental health several propositions have been made to account for their increased susceptibility to certain psychiatric illnesses. However, given the topic's multifacetedness, no single explanation is found sufficient in itself. 'Silencing the Self' theory sheds new light on this issue because it acknowledges the importance of social and cultural processes. Besides with its relational perspective, it centers on the primacy of core relationships and its influence on a woman's mental health. Even though, since its inception three decades ago, the theory has been studied in relation to various psychological and physical disorders; it has hitherto received inadequate attention by scholars. Nonetheless, it has the potential to inform our understanding when formulating women's mental health issues. The aim of this review is to provide a comprehensive narrative account of the extant work on 'silencing the self' in relation to psychiatric illnesses like depression, eating disorder and premenstrual dysphoric disorder. It attempts to synthesize the work done till date, as a starting point for further investigation of unexamined areas.

The burden of depressive disorders in South Asia, 1990-2016: findings from the global burden of disease study

BACKGROUND

Globally, depressive disorders are one of the most common forms of mental illness. Using data from the most recent Global Burden of Disease, Injury, and Risk Factor Study 2016 (GBD 2016), we aimed to describe the burden of disease attributable to depressive disorders in terms of prevalence and disability-adjusted life years (DALYs) in South Asia countries (namely India, Pakistan, Bangladesh, Nepal and Bhutan).

METHODS

GBD 2016 used epidemiological data on depressive disorders (major depression and dysthymia) from South Asia and a Bayesian meta-regression tool (DisMod-MR 2.1) to model prevalence and DALYs of depressive disorders by age, sex, country and year. DALYs were calculated from the years lived with disability (YLDs), derived from the prevalence of depressive disorders and disability weights, obtained from a community and internet-based surveys. The analyses adjusted for comorbidity, data sources and multiple modelling, and estimates were presented with 95% uncertainty intervals (UI).

RESULTS

In 2016, the age-standardised prevalence of depressive disorders in South Asia was 3.9% (95% UI: 3.6-4.2%), 4.4% (95% UI: 4.4-4.8%) in Bangladesh, 3.9% (95% UI: 3.6-4.2%) in India, 3.0% (95% UI: 2.8-3.3%) in Pakistan, 4.0% (95% UI: 3.7-4.3%) in Nepal and 3.7% (95% UI: 3.4-4.1%) in Bhutan. In South Asia, depressive disorders accounted for 9.8 million DALYs (95% UI: 6.8-13.2 million) or 577.8 (95% UI: 399.9-778.9) per 100,000 population in 2016. Of these, major depressive disorders (MDD) accounted for 7.8 million DALYs (95% UI: 5.3-10.5 million). India generated the largest numbers of DALYs due to depressive disorders and MDD, followed by Bangladesh and Pakistan. DALYs due to depressive disorders were highest in females and older adults (75-79 years) across all countries.

CONCLUSION

Our findings show the substantial public health burden of depressive disorders in South Asian populations and healthcare systems. Given the scale of depressive disorders, improvement in overall population health is possible if South Asian countries prioritise the prevention and treatment of depressive disorders.

Multilevel Influences on Depressive Symptoms among Men in Bangladesh

Depression is a worldwide problem, and is especially prevalent in lower-income countries with insufficient resources and widespread poverty, such as Bangladesh. Yet multilevel determinants of depressive symptoms in men have not been studied in this context. We leverage a novel dataset from men in Bangladesh to determine the community- and individual-level influences of masculine dominance strain and financial strain on the frequency of married men's depressive symptoms in Bangladesh. Data were collected between January and June, 2011, as part of the UN Multi-Country Study of Men and Violence, conducted by The International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b). Masculine dominance strain at both levels was related to the frequency of depressive symptoms. Financial strain only at the individual level was related to the frequency of depressive symptoms. We conclude that community-level economic interventions may not directly influence individual-level depression; however, addressing customary conceptions of masculinity at the community and individual level and addressing individual-level financial strain are promising joint strategies to improve married men's mental health in Bangladesh and similar settings.

Gender, Life Events, and Depression: An Exploratory Study

CONTEXT

Literature is inconsistent about the role of gender in mediating the relationship between life events and depression.

AIM

Our objective was to explore gender differences in patterns and frequencies of stressful life events before onset of a depressive episode.

SETTING AND DESIGN

Cross-sectional study at a tertiary care center.

SUBJECTS AND METHODS

One hundred patients fulfilling Diagnostic and Statistical Manual of Mental Disorders fourth edition criteria for current major depression (50 males and 50 females) were recruited for the study. Structured instruments were used to assess psychiatric comorbidity, episode severity, and stressful life events. We compared the number and frequency of stressful life events between genders and their relationship with demographic and clinical variables.

STATISTICAL ANALYSIS USED

Mann-Whitney U-test and Chi-square test.

RESULTS

Women with depression were older, more likely to be married (P < 0.01), had lower rates of comorbid panic disorder (P < 0.01) and nicotine dependence (P = 0.016) compared to men. Total stress scores and median number of stressful events in the year before onset of depression were significantly lower in women (P < 0.01). Getting married, job or property-related stressors, and breakup of friendship were more commonly reported stressors among males while more females reported dowry-related issues before symptom onset. In stratified analysis, these gender differences continued to hold good only in those with comorbid dysthymia.

CONCLUSION

There appears to be a sex-specific effect of certain life events on depression. Comorbid dysthymia may play an important role in mediating this differential stress sensitivity across genders.

How do people of South Asian origin understand and experience depression? A protocol for a systematic review of qualitative literature

INTRODUCTION

Individuals from Black and Asian Minority Ethnic (BAME) groups are less likely to receive a diagnosis and to engage with treatment for depression. This review aims to draw on international literature to summarise what is known about how people specifically of South Asian origin, migrants and non-migrants, understand and experience depressive symptoms. The resulting evidence base will further inform practices aimed at encouraging help-seeking behaviour and treatment uptake.

METHODS AND ANALYSIS

A systematic review and thematic synthesis of qualitative literature conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Using predefined inclusion and exclusion criteria, electronic searches will be conducted across 16 databases. Study quality will be assessed using the Critical Appraisal Skills Programme (CASP). Data will be extracted independently by 2 reviewers.

ETHICS AND DISSEMINATION

Ethical approval is not required. A comprehensive evidence base of how people from South Asian backgrounds conceptualise and experience depression will better inform the design and delivery of mental health initiatives and advance directions for future research. Findings will be published in a peer-reviewed journal, and disseminated through existing networks for professionals, researchers, patients and the public.

TRIAL REGISTRATION NUMBER

CRD42015026120.

Obstetric and psychosocial risk factors for Australian-born and non-Australian born women and associated pregnancy and birth outcomes: a population based cohort study

BACKGROUND

One in four Australians is born overseas and 47% are either born overseas or have a parent who was. Obstetric and psychosocial risk factors for these women may differ.

METHOD

Data from one Sydney hospital (2012-2013) of all births recorded in the ObstetriX database were analysed (n = 3,092). Demographics, obstetric and psychosocial risk profile, obstetric interventions and complications and selected maternal and neonatal outcomes were examined for women born in Australia and overseas.

RESULTS

Women born in Australia were younger, more likely to be primiparous (28.6 v 27.5%), be obese (32.0% v 21.4%), smoke (19.7 % v 3.0%), have an epidural (26.2% v 20.2%) and were less likely to have gestational diabetes mellitus (GDM) (6.8% v 13.7% when compared to non-Australian born women. The highest rates of GDM, Gestational Hypertension (GH) and maternal anaemia were seen in women born in China, the Philippines and Pakistan respectively. Differences were also seen in psychosocial screening between Australian and non-Australian women with Australian-born women more likely to smoke and report a mental health disorder. There was an association between having an Edinburgh Postnatal Depression Scale (EPDS) ≥ 13 and other psychosocial issues, such as thoughts of self-harm, domestic violence, childhood abuse etc. These women were also less likely to breastfeed. Women with an EPDS ≥ 13 at booking compared to women with EPDS ≤12 had a higher chance of being diagnosed with GDM (AOR 1.85 95% CI 1.14-3.0).

CONCLUSIONS

There are significant differences in obstetric and psychosocial risk profiles and maternal and neonatal outcomes between Australian-born and non-Australian born women. In particular there appears to be an association between an EPDS of ≥13 and developing GDM, which warrants further investigation.

Cultural variations in interpretation of postnatal illness: Jinn possession amongst Muslim communities

Maternal experience of emotional and physical disturbance during the postnatal period is a worldwide occurrence but may be interpreted differently according to cultural background. Little is known about different expressions and treatment of cultural phenomena during the postnatal period such as the affliction of Jinn possession in Arabic cultures. Jinn are considered to be evil spirits, which cause emotional and physical distress at times of vulnerability such as the postnatal period. The aim of this paper was to explore maternal experience of Jinn possession and draw parallels with Western interpretations of postnatal illness. Ten women in an Arabian Gulf state who had recently given birth and identified themselves as having Jinn possession were interviewed as to their experiences of Jinn possession. Mothers described the Jinn as evil spirits who cause symptoms such as sadness, anxiety and physical malaise during the postnatal period. Numerous risk factors for possession emerged such as lack of familial support, poverty and a traumatic birth. Clear parallels emerged between Western concepts of postnatal illness and Jinn possession. Mothers in Muslim cultures may experience Jinn possession during the postnatal period, which reflects similar symptoms and aetiology to Western concepts of postnatal illness. With increasing multiculturalism in the UK, understanding the origins and perception of Jinn possession is important for health professionals working in Muslim communities here.

Social relationships and postpartum depression in South Asia: a systematic review

BACKGROUND

Evidence suggests a much higher prevalence of postpartum depression in South Asia than in 'western' contexts.

AIM

To conduct a rapid systematic review of evidence on the association between social relationships and postpartum depression in South Asia.

METHODS

Five databases were searched to identify relevant studies. Studies meeting the selection and quality criteria were analysed and integrated in a narrative review.

RESULTS

Nine mostly quantitative studies were included in the review. Low support and poor relationships with the husband and parents-in-law were associated with postpartum depression, although associations were weakened in multivariate analyses. The different dimensions of support have not yet been systematically investigated and the likely complex interrelationships between social relationship risk factors are not yet well understood.

CONCLUSIONS

Findings mirror those from 'western' contexts, showing the key role of social relationships in the aetiology of postpartum depression. Yet, they also reinforce the hypothesis that the social and cultural context influences the association. The importance of relationships with the extended family, as well as the husband, in South Asia is highlighted. Further research is recommended to develop an understanding of these relationships to better inform interventions.

Issues in the evaluation and treatment of anxiety and depression in migrant women in the perinatal period

OBJECTIVES

Perinatal depression and anxiety are prevalent in migrant women. The main aims of this literature review were to understand the psychosocial determinants of depression and anxiety in migrant women antenatally and to explore common clinical presentations. In addition, we aimed to identify barriers and facilitating factors for help-seeking and treatment, in order to identify directions for service development and improvement.

METHODS

A review of the literature was performed using electronic databases.

RESULTS

Depression and anxiety are over represented in migrant women in the perinatal period. Somatic symptoms are common presentations for emotional distress. An identified difficulty is a perceived lack of support, often as a result of cultural dislocation and social isolation. Significant barriers to help-seeking include the perception that limited assistance is available and reluctance to share personal information with an unknown clinician. Preferred therapeutic approaches include the use of clinical consultants from the same or similar culture, as well as practical and emotional support rather than medical management of symptoms.

CONCLUSION

Clinicians should be aware of psychosocial issues in this vulnerable population. Group programmes with a focus on education about mental and physical health, available supports, and socialisation are effective in engaging and assisting pregnant migrant women.

Malaysian Moslem mothers' experience of depression and service use

Standard psychiatric criteria for depression developed in the United States and United Kingdom are increasingly used worldwide to establish the prevalence of clinical disorders and to help develop services. However, these approaches are rarely sensitive to local and cultural expressions of symptoms or beliefs about treatment. Mismatch between diagnostic criteria and local understanding may result in underreporting of depression and underutilization of services. Little such research has been conducted in Malaysia, despite the acknowledged high rate of depression and low access to services. This study examines depression in Moslem Malay women living in Johor Bahru, Southern Peninsular Malaysia, to explore depression symptoms using the Structured Clinical Interview for DSM-IV. The 61 women interviewed were selected on the basis of high General Health Questionnaire scores from a large questionnaire survey of 1,002 mothers. The illustrative analysis looks at descriptions of depressed mood, self-depreciation and suicidal ideation, as well as attitudes toward service use. The women gave full and open descriptions of their emotional symptoms, easily recognizable by standard symptom categories, although somatic symptoms were commonly included, and the spiritual context to understanding depression was also prevalent. However, few women had knowledge about treatment or sought medical services, although some sought help from local spiritual healers. Attending to such views of depression can help develop services in Malaysia.

Indian culture and psychiatry

'Culture' is an abstraction, reflecting the total way of life of a society. Culture uniquely influences mental health of people living in a given society. Similarity in thinking and understanding of mental health across the ancient cultures has been observed. Studies which relate to the demographic factors, cultural factors influencing presentation of illness, diagnosis of the illness-culture bound syndromes and influence of the cultural factors and the belief system on psychopathology, stigma and discrimination towards the patient have been reviewed. An attempt has been made to critically look at the research on culture and psychiatry in different areas. There is a need for culturally oriented modules of non-pharmacological management.

Understanding and managing somatoform disorders: Making sense of non-sense

Somatization is a clinical and public health problem as it can lead to social dysfunction, occupational difficulties and increased healthcare use. Hence understanding somatoform disorders is of paramount importance, especially so in developing countries like India. This paper discusses the history and evolution of the concept of somatization and somatoform disorders, etiological considerations, classification, assessment, diagnosis and clinical management. Research from India, controversies and criticisms and future perspectives are mentioned. A new model to understand functional somatic symptoms, in Indian setting is also proposed.

The associations between menopausal syndrome and depression during pre-, peri-, and postmenopausal period among Taiwanese female aborigines

AIM

The aim of the study was to evaluate the association between physiological menopausal symptoms and depression during the pre-, peri-, and postmenopausal period among female Taiwanese aborigines.

METHODS

A total of 672 Taiwanese aboriginal women, aged 40-60 years, were recruited in the interviewing study and classified as pre-, peri-, and postmenopausal according to menstrual bleeding patterns in the previous 12 months. Then, the postmenopausal symptoms, depression, self-perceived health, family support, and associated demographic variables were assessed by questionnaire based on the results of interviewing by research assistants.

RESULTS

The results revealed that perimenopausal statuses are associated with depression and women with a perimenopausal status had a higher prevalence of depression than those with a premenopausal status. A higher score on physiological postmenopausal symptoms was found to be significantly associated with depression. Furthermore, somatic symptoms were associated with depression for pre-, peri-, and postmenopausal statuses. Moreover, sexual dysfunction and vasomotor symptoms were associated with depression only in the premenopausal status and postmenopausal status, respectively.

CONCLUSION

Depression should be routinely evaluated for female Taiwanese aborigines consulting with physicians for menopause symptoms, especially for somatic symptoms. Furthermore, attention should be provided to premenopausal women with sexual dysfunction and postmenopausal women with vasomotor symptoms for depression.