Socio-Demographic Factors and Their Correlation with the Severity of Major Depressive Disorder : A Population Based Study

Objective: Genetic and neurobiological factors are considered to be the major causes of major depressive disorder (MDD). However, over last few years study results revealed that socio-demographic factors contribute a significant role in abnormal functional activity and recognized as major causative factors to the pathogenesis and severity of MDD. The aim of this study was to assess the socio-demographic characteristics of Bangladeshi MDD patients and to discover their role on the severity of disease. Material and Methods: A retrospective review of the case notes of psychiatry outpatients at Bangabandhu Sheikh Mujib Medical University (BSMMU) was carried out between Sep-Nov 2016. A total of 234 MDD patients (aged 18 to 60 years) were randomly recruited. Relevant information was obtained by collection of prescription details from the patients or their relatives by face to face interview. Results: Mean age and body mass index (BMI) were found 34.734 years (SEM ± 0.842) and 22.014 kg/m respectively. Among all respondents, 56% (133) were male and 44% (106) were female where mean income was 26.84 KBDT (Kilo Bangladeshi Taka) (SEM ± 0.749). Roughly 46% (111) patients were found to be below secondary level of education. Married people (56%) had a tendency to develop depression compare to unmarried people (36%). Urban residents (64%) are more prone to suffer from depression than rural residents (36%). There was mild depression in 28% (68), moderate in 37% (157), and severe in 14% (34) patients. Correlation analysis shows that age, sex, marital status, education, family income, and area of residence (p-values 0.004, 0.001, 0.000, 0.011, 0.000 and 0.000, respectively) are associated with the severity of disease. Moreover, among all significant correlations age, marital status and area of residence were positively correlated with the severity of MDD (r = 0.184, r = 0.238 and r = 0.256) while sex, education and family income were negatively correlated with the severity of depression (r = −0.207, r = −0.164 and r = How to cite this paper: Islam, Md.R. and Adnan, R. (2017) Socio-Demographic Factors and Their Correlation with the Severity of Major Depressive Disorder: A Population Based Study. World Journal of Neuroscience, 7, 193-202. https://doi.org/10.4236/wjns.2017.72014 Received: February 2, 2017 Accepted: March 6, 2017 Published: March 9, 2017 Copyright © 2017 by authors and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY 4.0). http://creativecommons.org/licenses/by/4.0/ Open Access Md. R. Islam, R. Adnan 194 −0.722). Conclusion: Current study shows that age, gender, marital status, education, family income, and area of residence are associated with the severity of depression. Age, marital status and residence of MDD patients are positively correlated with the severity of disease while gender, education and family income are negatively correlated with the severity of depression. It is predicted that this study will be helpful for the management and assortment of MDD patients with more accuracy based on their socio-demographic features.


Introduction
Major depressive disorder (MDD) is considered as a persistent feeling of hopelessness or a lack of interest in external drives which is accompanied by low selfesteem and loss of pleasure or interest in daily events that unfavorably disturbs a person's family, effort and personal life [1].Medical journal Neuron mentioned that she reedited as a fundamental cause of depression with almost 3-fold increased risk in the first-degree relatives of persons with MDD compare to general population [2].This means that the single biggest determining factor for depression is family tree, but there also is a significant physiological and anatomical basis [3].However, over the past few years, socio-demographic characteristics involved in abnormal functional activity have been recognized as major causative factors to the pathogenesis and severity of MDD [4].Based on previous studies, risk factors for depressive illness in the elderly can be grouped into psychosocial, biological, personality characteristics, medication and socio-demographic factors [5].Psychosocial factors include stressful life events e.g.bereavement, financial failures, loneliness etc. [6].Biological factors include: female gender, folate and vitamin B 12 deficiency, "vascular depression" where stroke is implicated and chronic or severe physical pain [7].Personality traits include low self-esteem, extreme dependency and pessimism [8].Medication includes anxiolytics, tranquilizers, anti-inflammatory, anti-infective agents, beta and calcium channel blockers, hormonal agents, cardio tonic drugs and alcohol [9].Finally, socio-demographic factors related with depression are low socio-economic status, poor educational background, and widowhood [10].
Age, gender, education, income, and marital status have been identified as important contributing factors for the variability and prevalence of depression.
Many studies established that prevalence rate of depression varying from 2.8% to 10.3% based on socio-demographic factors e.g.age and gender [11] [12] [13].
Patten et al. found significant correlations among age, gender, and marital status of single women reporting lower rates of depression [14].Some previous research also found that age is the main demographic feature that contributes much in the prevalence of depression [13].Women's prevalence of depression also differs by age, over 65 years of age 3.1% women suffer from depression and 9.6% for the age group 12 to 24 [13].Occurrence of depressive episode has also been significantly depends on gender [15].Usually risk factors for having depression is 2 -3 fold higher with females compared to males [11] [12] [13] [16].
In addition to gender, marital status has also been identified as major contributing factors for the variance in the prevalence of depression.In Australia, separated and divorced people suffer more from anxiety disorders (18%) and affective disorders (12%) [17].In Canada, prevalence of depression was found 15.4% among single mothers compared to 6.8% in married mothers [18].Many studies endorsed a strong opposite relationship between mental disorder and socioeconomic status [15] [19] [20] [21].
In Bangladesh, 4.6% population have any form of depression and among all psychiatric patients, 28.7% suffer from major depressive disorder.Both females and singles have a tendency to suffer from depression more than others [22].
Many studies showed that the chance of having major depression is double in women than men but the reason is unknown and which factors actually responsible for this are also unknown [23].People usually experience their first episode of depression during the fourth decade of life and there may be a second smaller peak at the age between 50 to 60 years.Chance of having depressive episodes is associated with some states of diseases such as Parkinson's disease, stroke, or multiple sclerosis [24].

Material and Methods
A retrospective review of the case notes of outpatients was carried out from September to November 2016.A total of 238MDD patients, age ranging from 18 to 60 years, were randomly recruited from the outpatient Department of Psychiatry, Bangabandhu Sheikh Mujib Medical University (BSMMU) Hospital, Bangladesh.Patients under the age of 18, above the age of 60 or those having a severe general medical condition were not included in the study.A specialist psychiatrist conducted the diagnosis and interview of the patients based on Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V, 2013) [25].Where physician generally notice few mental changes of patients to be diagnosed as MDD e.g.depressed mood or a loss of interest or pleasure in daily activities for more than two weeks, mood represents a change from the person's baseline and impaired social, occupational and educational activities.Along with the above changes at least 5 specific symptoms (out of 9) will also be present nearly every day in MDD patients.Severity of depression is categorized as mild, moderate and severe.Mild depression, where 5 -6 specific symptoms were present and functional impairment was also mild.Moderate depression, where 7 -8 specific symptoms were present and moderate functional impairment was also present.Severe depression is termed as where most of symptoms were present with severe functional impairment, recent suicide attempt, or has specific suicide plan or clear intent.The data were taken by collection of prescription details from the patients or their relatives by face to face interview with them.
The study subjects were informed about the objective of the study and a written consent was taken from each of them.Each of the subjects filled up a questionnaire form which contains personal information, socio-economic data, history of illness, family history and other demographic and medical information.The forms of the patients who had no formal education were filled out with the help of their primary care givers.Study protocol and volunteer consent form was approved by the ethical review committee of Department of Psychiatry, BSMMU.
Statistical analysis was performed using the statistical software package SPSS, version 23.0 (SPSS Inc., Chicago, IL).Descriptive data has been given as frequencies and percentages.

Results
The socio-demographic characteristics of the respondents are shown in Table 1.
Approximately 59% (141) patients were found within an age range of 25 -44 years.Average body mass index (BMI) was found 22.014 kg/m 2 where 74% (178) patients were in normal BMI range.Among all respondents, 56% (133) were male and 44% (106) were female.Roughly 46% (111) patients were found to be below secondary level of education, whereas 17%, 19% and 18% respondents had education equivalent to secondary, higher secondary and graduation or higher respectively.Mean values of socio-demographic factors of study population were expressed in Table 2 where patients had a mean age of 34.734 years (SEM ± 0.842).Among all respondents 33% were jobless as well as having family income below 10 KBDT (Kilo Bangladeshi Taka) and their mean income was 26.84 KBDT (SEM ± 0.749).As per the finding of current study, married people (56%) had a tendency to develop depression than unmarried people (36%).Twenty percent of depressed person had their family history of any psychiatric disorder.

Correlation analysis between socio-demographic factors and severity of MDD
was given in Table 3.Our current study shows that there was statistically significant correlation between different socio-demographic parameters and severity of depression.Results from correlation analysis shows that at 95% confidence interval age, sex, marital status, level of education, monthly income, and area of residence (p-values 0.004, 0.001, 0.000, 0.011, 0.000 and 0.000, respectively) are associated with disease severity while BMI (p-value 0.175) and smoking habit (p-value 0.960) were not significantly correlated with severity of depression.
Moreover, among all significant correlations age, marital status and area of residence were positively correlated with the severity of MDD (r = 0.184, r = 0.238 and r = 0.256) while sex, education and family income were negatively correlated with the severity of depression (r = −0.207,r = −0.164and r = −0.722).

Discussion
This study was conducted to explore the socio-demographic status of MDD patients attending at outpatient department of a tertiary care teaching hospital in Bangladesh.Also find out the correlation between socio-demographic status and severity of the disorder.Our study findings were comparable with similar previous studies in some other countries.As per current study approximately 59% patients were found within an age range of 25 -44 years where 74% patients were in normal BMI range.Similar result was stated in another study where they found people usually experience depressive episode during their forth decade of life [24] and more than 50% patients had normal body weight [26].We found 56% male and 44% female patients as per this study which is not similar with some previous study results where reported that chance of having major depression is twice in women than men [23].Actual fact behind this inconsistent result is our social behavior to psychiatric patients because they are neglected especially for female patients compare to any patients suffering from other diseases.
About 46% patients were found below secondary level of education, 17%, 19% and 18% were corresponding to secondary, higher secondary and graduation or higher, respectively.The results are comparable with previous studies reporting associations between individuals with educational status and depression, e.g.
significantly more incidents of MDD occur among those with lower educational background [27].Among all respondents 33% were jobless as well as having family income below 10 KBDT (Kilo Bangladeshi Taka) which is consistent with study results in China that is lower socioeconomic status is linked with augmented rates of depression [27].We found married people had a tendency to develop depression than unmarried people.This result is consistent with other previous studies where married person had increased risk to fall in depression in both genders [28].As per our study result, people with family history of any psychiatric disorders had increased risk to develop depression which is supported by some other study findings [29].Urban residents are more prone to suffer from depression than rural residents which also similar with other findings [30].
Results from correlation analysis shows that age, sex, marital status, level of education, monthly income, and area of residence were associated with the severity of disease while BMI and smoking habit were not significantly correlated with severity of depression.Furthermore, age, marital status and area of residence were positively correlated with the severity of MDD while sex, education and family income were negatively correlated with the severity of depression.A study among Chinese people supported these findings where age, study year, satisfaction with major, family income situation, parental relationship and mother's education were significantly associated with depression [31].
The limitation of our current study was we did not explore any biological parameters in MDD patients although alterations of some of these elements may play an important role for developing depression.Therefore, further study may be required to determine whether social conditions influence on the severity of depression or other biological markers influence depression more.Another drawback of our present study was we took samples from single center.So, if we want to produce more accurate conclusion for our present study, we need to carry out this study over large number of samples from different regional part of Bangladesh.In spite of these limitations, we hope our study will play an important role to understand the association between socio-demographic status and severity of depression.

Conclusion
This study shows that age, sex, marital status, level of education, monthly income, and area of residence were associated with the severity of depression.Age, marital status and residence of MDD patients are positively correlated with the severity of disease while sex, education and family income are negatively correlated with the severity of depression.This strong association between depression and socio-demographic status will play an important role to understand and treat the disease.It is anticipated that this study will be helpful for not only management of MDD but also assortment of patients with more precision based on their socio-demographic features.

Figure 1 .
Figure 1.Distribution of MDD patients based on the severity.

Table 1 .
Socio-demographic status of major depressive disorder patients described as frequencies and percentages.

Table 2 .
Socio-demographic factors of study population (mean values with standard error mean).

Table 3 .
Correlation between socio-demographic factors and severity of major depressive disorder.
r = Correlation co-efficient; p = Significance; Negative values specify opposite correlation.* Correlation is significant at 0.05 level (two-tailed).