الفهرس 
Acknowledgement
Aim of the workOnly 14 pages are availabe for public view
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Abstract
The present work is a cross-sectional study among patients attending outpatient clinics of Assiut University Hospitals during one year period. The study was conducted during the period from June 1st 2006 to may 31st 2007 aiming at estimation of the percentage of depressive disorders among patients attending various outpatient clinics of Assiut University Hospitals.
Studied sample in the present work included 2304 patients aged 15 years and above. Subjects were recruited from different outpatient clinics of the hospital.
The sample size was determined based on the following equation:
N= (Z 1-α/2)2 p (1-p)/D2
N= sample size
Z 1-α/2= number of standard error from the mean.
P= proportion of the best guess about the value of the proportion of the interest.
D= the absolute precision required on either side of the proportion, or the distance; how close to the proportion interest.
The estimate is desired to be: when confidence level= 95%.
Using a systematic random sampling technique, a sampling interval of 10 was obtained.
Initial sheet was applied to all individuals to collect data about name, sex, residence, educational level, marital status, family size and special habits. Initial sheet also included data about the clinical diagnosis, duration of the current illness, treatment (if any) and its duration, patient’s response to treatment and finally history of any psychiatric illnesses and their durations.
Selected subjects were then interviewed for the presence of depressive symptoms using the Beck Depression Inventory scale (BDI) (Beck 1988). Socio-economic status of screened individuals was determined using the modified version of socioeconomic scale for family (Abdel-Tawab 1998) that assess for family income, educational level, occupational status, and family life style (i.e. residence, expenses, activities, and possessions).
In the next step, all subjects detected to have depression (scoring 4 or more on BDI scale) were subsequently evaluated through the following scales:
1- Psychiatric sheet especially prepared for the present work and used in performing the psychiatric interview. Diagnosis was made on the basis of DSM-IV TR (APA 2000) criteria. Medical and neurological examination data were also included in the sheet.
2- Suicidality sheet of the Mini International Neuropsychiatric Interview (MINI) plus English Version 5.0.0 (Sheehan et al 1998) that addresses risk of suicide among depressed patients.
3- Sheehan Disability Scale (Sheehan 1983) was used to assess functional impairment in three inter-related domains; work/school, social and family life. The patient rates the extent to which work/school, social life and home life or family responsibilities are impaired by his or her symptoms on a 10 points visual analog scale. The three items are summed into a single dimensional measure of global functional impairment ranging from 0 (unimpaired) to 30 (highly impaired).
4- Mixed Anxiety-Depression scale of the MINI plus English Version 5.0.0 that assesses for the presence of anxiety symptoms comorbid with depressive symptoms.
Administration of Beck Depression Inventory (BDI) to the surveyed sample (2304 subjects) has yielded 202 subjects with depression (Scored 4 or more on BDI scale) representing 8.8% of the whole sample.
All 202 subjects underwent the diagnostic phase. As stated above, psychiatric diagnosis was made on the basis of DSM-IV TR criteria deduced from a well constructed psychiatric interview. Overall, of 202 patients with depressive disorders, 167 patients (82.7%) were classified as having major depressive disorders, 28 patients (13.9%) were assessed to have depressive disorder NOS (26 patients (12.9%) with minor depression and only 2 patients (1%) with postpartum depression), 5 patients (2.5%) were diagnosed with dysthymic disorder and finally 2 patients (1%) with bipolar disorder, depressive episode.
The mean age of patients with depressive disorders in the present work was 42.48 ± 12.39 years. Results revealed that percentage of depressive disorders was significantly higher among females in the age group (35-55) years.
As regard sex, the percentage of female subjects with depressive disorders was significantly higher than males with female to male ratio almost approaching 1.89:1.
As regard education, depressive disorders were significantly higher among individuals who are highly educated or literate compared to illiterate ones. For residence, depressive disorders were significantly higher among urban compared to rural residents.
As regard occupational status, depressive disorders were significantly higher among unemployed males. Regarding type of job, depressive disorders were significantly higher among skilled workers and employees compared to non-skilled workers.
Regarding marital status, depressive disorders in the study were significantly higher among divorced/widowed/separated individuals when compared to single or married ones. As regard socioeconomic level, there was no significant relationship between percentage of depressive disorders and socioeconomic level of studied individuals. Also, socioeconomic level had no effect on severity of depression in patients with depressive disorders in the study. Depressive disorders were significantly higher among male smokers compared to non-smokers in the present study.
As regard medical diagnoses, depressive disorders were significantly higher among patients with certain medical conditions (e.g. malignancy, disfiguring conditions, autoimmune conditions, renal diseases and hepatic diseases). Additionally, depressive disorders were significantly higher among individuals presenting with ”two” and ”more than two” concurrent medical conditions compared to those having single medical condition. Severe forms of depression were more prevalent among patients presenting with malignant conditions, loss of vision, disfiguring conditions, liver diseases, cerebrovascular accidents, painful conditions and finally diabetes mellitus and its complications.
As regard treatment, depressive disorders were significantly higher among patients on regular hemodialysis, those receiving chemotherapy, steroids or interferon and also among patients who underwent surgery. Severe forms of depression were found among patients who underwent surgery and those receiving steroids, chemotherapy, digoxin, antidiabetics and nootropics and also among patients on regular dialysis for chronic renal failure.
Regarding duration of medical illness, we reported a significant relationship between duration of current medical condition and occurrence of depression in the studied sample, with higher percentage among patients who have been sick for more than 24 months. However, severity of depression was not related to duration of medical illness.
As regard recurrence of depression, 55 out of 202 patients (20.3%) with current episode of depression were found to have history of recurrent depressive disorders. Recurrence of depression was significantly higher among patients with certain medical disorders such as autoimmune conditions, liver diseases, renal diseases, cardiac conditions and diabetes, probably because of the long lasting nature of these medical disorders and frequent follow up visits in the outpatient clinics. Recurrence of depression was significantly higher among patients who have been sick for more than 24 months.
Results revealed that the recurrence of depression is significantly higher among patients presenting with current moderate to severe depression compared to those with minor or mild depressive episodes. On the other hand, we did not find relation between recurrence of depression and overall medical burden or patients’ occupational status or their socioeconomic level.
Regarding duration of current depressive episode, we reported a significant relationship between duration of current medical condition and duration of current depressive episode, particularly for patients who have been sick for more than 24 months
Positive family history of depression was found in 29 patients representing 14.4 % of the total sample. Positive family history of depression is significantly higher among patients having ”severe depression with psychotic features” compared to those with ”severe depression without psychotic features” or other forms of depression. Additionally, recurrence of depression is significantly higher among patients with positive family history of depression.
As regard consanguinity between parents and depression, our results revealed that consanguinity between parents was not associated with increased percentage of depression in studied individuals.
Regarding degree of impairment in patients with depressive disorders, it was found to be significantly higher among patients presenting with moderate and severe forms of depression, and particularly in patients with severe depression with psychotic features, compared to those with minor or mild forms of depression.
As regard suicidality among patients with depressive disorders, we found out that suicidality was significantly higher among patients with severe depression, and particularly among patients with severe depression with psychotic features
Significant anxiety symptoms (e.g. feeling tired or low in energy, persistence worry or feeling irritable) were found in up to 62.4% of patients with depressive disorders in the present study. Results revealed that anxiety symptoms were neither associated with specific depressive disorder nor with the severity of current depressive episode.
Lastly, as regard symptoms of depression in the study, depressed mood was reported in all patients with depressive disorders in the studied sample. Decreased appetite and psychomotor retardation were reported in nearly 85% of depressed patients. This is followed in order of decreasing frequency with anhedonia (76.7%), anergia (76%) and decreased ability to concentrate (75.25%).
Conclusions
Depression is a common mental health problem, seen frequently in general medical settings. The problem is as frequent in our community as elsewhere. This study showed that depression was significantly higher among female subjects (particularly in the age group 35 -55 years), male smokers, highly educated and literate individuals, non-working males and among divorced/widowed/separated individuals. Depressive disorders were also significantly higher among patients with certain medical conditions (e.g. malignancy, disfiguring conditions, autoimmune conditions, renal diseases and hepatic diseases) and among those who had more than one medical condition. This study also revealed that depressive disorders were significantly higher among patients receiving specific treatment modalities such as chemotherapy, steroids and interferon and also among patients who underwent surgery and those on regular dialysis.
The study showed that degree of impairment was significantly higher among patients with moderate and severe depression, and particularly in patients with severe depression with psychotic features. Also, suicidality was significantly higher among patients with severe depression, and particularly among those with severe depression with psychotic features.
On the other hand, although anxiety symptoms were encountered in a significant proportion of depressed patients, results revealed that anxiety symptoms were neither associated with specific depressive disorder nor with the severity of current depressive episode.
When we compared the common presenting symptoms in the present work with most other community and hospital based studies, we didn’t detect any significant differences regarding the distribution of the common presenting depressive symptoms. It follows that depressive symptoms among medically ill patients are just similar to that in general population. This might facilitate the detection of depression in medically diseased patients because there no highly specialized screening tools are needed to pick up depression in those patients.