depression in malay women with low socio-economic …
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DEPRESSION IN MALAY WOMEN WITH LOW SOCIO-ECONOMIC STATUS:
PREVALENCE, AND RISK FACTORS
BY
MERIAM OMAR DIN
INTERNATIONAL ISLAMIC UNIVERSITY MALAYSIA
2008
DEPRESSION IN MALAY WOMEN WITH LOW SOCIO-ECONOMIC STATUS:
PREVALENCE, AND RISK FACTORS
BY
MERIAM OMAR DIN
A thesis submitted in fulfillment of the requirement for the degree of Doctor of Philosophy (Psychology)
Kulliyyah of Islamic Revealed Knowledge and Human Sciences
International Islamic University Malaysia
JUNE 2008
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ABSTRACT
A community study was conducted to examine (1) the prevalence of current depression and lifetime depression in rural and urban women with low socio-economic status (SES), and (2) the relationship between different risk factors and the rate of current depression. Data were collected from a total of 487 respondents (N rural=242, N urban=245) in the first interview, and selected 120 respondents (N rural=60, N urban=60) in the second interview. The data consisted of seven socio-demographic variables and ten psychosocial risk factors. Four types of standardised measurements were used: Center for Epidemiologic Studies Depression Scale (CESD), Rosenberg Self-Esteem Scale (R-SES), Interpersonal Support Evaluation List (ISEL), and Parental Bonding Instrument (PBI). The results indicated that the prevalence rate of current depression was 11.5% and the rate of lifetime major depression was 27.5%. No significant effect of socio-demographic factors on the rate of current depression was found. Although there was a significantly higher rate of current depression in the urban sample, no definite conclusion could be drawn on the significance of the SES variables as predictors of current depression. Seven psychosocial risk factors namely lifetime major depression, lifetime dysthymia, current life stressors, family history of mental health problems, adverse childhood experiences (ACEs), self-esteem, and social support were significantly associated with depression in the expected direction. Except for ACEs, these factors were significant predictors of current depression accounting for 25% of the variance in the rate of current depression. The interaction effect of age and family history of mental health problems on the rate of current depression was found to be significant. Overall, the results were not able to fully support the hypothetical model used in the study. Two alternative models with good fitness indices were presented. The relatively higher prevalence of depression in this study as compared to past studies may reflect the high prevalence of depression in Malay women with low SES. This may also be due to other additional socio-cultural factors such as devalued women’s mothering and home-making roles and additional psychological stress experienced by urban women with low SES.
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ملخص البحث
ة والكآبة المزمنة لدى النساء ذواتمدى شيوع الكآبة الحالي) 1(تم إجراء دراسة مجتمع لاختبار والعلاقة بين عوامل الخطر ) 2(المستوى الاجتماعي والاقتصادي المنخفض في المناطق الريفية وفي المدن
امرأة من مناطق 242(امرأة 487لى من جمعت البيانات في المقابلة الأو. المختلفة والكآبة الحاليةمن 60من مناطق ريفية، و 60(امرأة 120، ثم تم اختيار )امرأة من مناطق حضرية 245ريفية، و
تألفت البيانات من سبعة . ممن يعانين من مستويات عالية من الكآبة في المقابلة الثانية) مناطق حضريةتم استخدام أربعة أنواع من . اجتماعية-مل خطر نفسيةديموغرافية، وعشرة عوا-متغيرات اجتماعية
، ومقياس )CESD(مقياس مركز دراسات علم الأمراض للكآبة : القياسات المعيارية في الدراسة، وهي، وآلة الترابط )ISEL(، وقائمة تقويم الدعم بين الأشخاص )R-SES(روزنبرج للاعتزاز بالنفس
، وأن معدل %11.5إلى أن معدل شيوع الكآبة الحالية هو أشارت نتائج الدراسة ). PBI(الأبوي لم تكن هناك علاقة ترابط مهمة بين العناصر %. 27.5شيوع نوبات الكآبة الكبرى هو
الديموغرافية ومعدلات الكآبة، على الرغم من وجود معدلات كآبة مرتفعة لدى العينة - الاجتماعيةإلى نتيجة مؤكدة حول أهمية العلاقة بين الوضع ولم يكن بالإمكان الوصول . التي تسكن المدن
كانت للعوامل الاجتماعية والنفسية السبعة المتمثلة . الاجتماعي والاقتصادي والكآبة لدى عينة البحثفي نوبات الاكتآب الكبرى، وخلل التوتة، وضغوطات الحياة، وتاريخ العائلة للمشاكل العقلية،
عتزاز بالذات، والدعم الاجتماعي، صلة مهمة بالكآبة في الاتجاه وتجارب الطفولة السلبية، ومدى الامتغيرات منبئة لمتغير الكآبة، -ما عدا عنصر تجارب الطفولة السلبية–وكانت تلك المتغيرات . المتوقع
كما كان أيضاً للسن، ولتاريخ . من نسبة التغير في معدلات الكآبة% 25وقد شكلت تلك المتغيرات لم تستطع النتائج دعم النموذج الافتراضي . ل العقلية أثراً مهماً على مستويات الكآبةالعائلة للمشاك
إن شيوع الكآبة . وقد تم تقديم نموذجين بديلين ذوي مؤشرات مطابقة جيدة. المستخدم في الدراسةضع المرتفع نسبياً في هذه الدراسة قد يعكس معدل الكآبة المرتفع لدى النساء الملايويات ذوي الو
وقد يعود هذا التباين في معدلات الكآبة إلى عناصر اجتماعية . الاجتماعي والاقتصادي المنخفضكما يمكن أن مستوى الكآبة المرتفع نسبياً لدى سكان المدن من النساء ذوي المستوى . وثقافية أخرى
سية الإضافية الملقاة الإجتماعي والاقتصادي المنخفض قد يعود إلى دور النساء في المترل، والضغوط النف . على عاتقهن
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APPROVAL PAGE
The thesis of Meriam Omar Din has been examined and approved by the following:
Noraini Mohd Noor
Supervisor
Rahmattullah Khan Abd Wahab Khan
Second Supervisor
Hariyati Shahrima Abdul Majid Internal Examiner
Nora Mat Zin Internal Examiner
Teoh Hsien-Jin External Examiner
Nasir Eldin Ibrahim Ahmed Chairman
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DECLARATION
I hereby declare that this dissertation is the result of my own investigations, except
where otherwise stated. I also declare that it has not been previously or concurrently
submitted as a whole for any other degree at IIUM or other institutions.
Meriam Omar Din
Signature……………………………….. Date……………………………...
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INTERNATIONAL ISLAMIC UNIVERSITY MALAYSIA
DECLARATION OF COPYRIGHT AND AFFIRMATION OF FAIR USE OF UNPUBLISHED
RESEARCH Copyright © 2008 by Meriam Omar Din. All rights reserved.
DEPRESSION IN MALAY WOMEN: PREVALENCE, RISK FACTORS AND TREATMENT
No part of this unpublished research may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without prior written permission of the copyright holder except as provided below.
1. Any material contained in or derived from this unpublished research may only be used by others in their writing with due acknowledgement.
2. IIUM or its library will have the right to make and transmit copies
(print or electronic) for institutional and academic purposes.
3. The IIUM library will have the right to make, store in a retrieval system and supply copies of this unpublished research if requested by other universities and research libraries.
Affirmed by Meriam Omar Din. ……………………………… ………………………. Signature Date
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To my beloved husband and four wonderful children – Azam, Lina, Wati and Ami
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ACKNOWLEDGEMENTS
In the name of Allah, Most Gracious and Most Merciful, I am thankful to you for providing me good health, active mind and the energy to
conduct and complete the research work peacefully.
I would like to acknowledge several people for their great contributions in making it
possible for me to complete my thesis.
First and foremost, I would like to express my appreciation and gratitude to my
supervisor, Professor Dr. Noraini Mohd Noor, for providing me invaluable guidance,
knowledge and skills in research method and report writing. You have all the
qualities of a supervisor I needed; your high commitment, passion, promptness,
helpfulness and trust have indeed motivated me to continue working on the thesis and
enabled me to complete it within the expected time.
I would also like to thank my second supervisor, Associate Professor Dr
Rahmatullah Khan Wahab Khan, for providing me valuable insight in my first
experience of an experimental research and to Professor Dato’ Dr Wan Rafaei Abdul
Rahman for his useful guidelines given during the colloquium.
My deep appreciation goes to Professor Emeritus Dato’ Dr. Abdul Halim
Othman and Associate Professor Dr Wan Abdul Kader Wan Ahmad who have helped
me acquire counseling skills; and my supervisees, Mardiana and Shen, who have
given me the opportunity to supervise CCT practices as part of their academic
requirement. These experiences helped to improve my confidence in conducting the
clinical study.
Many thanks to the personnel of FELDA, Kuala Lumpur City Council, Kuala
Lumpur Hospital and ACCESS Counselling Services, especially to Dato’ Dr Abdul
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Aziz, Dr Lim, Mohd Kadri, Azizah, Maznah, Sister Hamidah and Esah Bee for giving
me the necessary assistance during my field work.
I would also like to convey my gratitude to Fauzana and Sharmin for helping
me with the administration of research work and to the team of interviewers; Ainaa,
Farazira, Intan, Norazida, Norhuda and Zuraiti. I am profoundly grateful to the team
leader, Nurul Aishah, for her patience and commitment in leading this challenging
field work until its completion.
To UIA practical students, Nurul and Azizah, thank you for helping me in the
initial data entry and presentation of my research progress, and to Earla for editing my
research proposal. My appreciation goes to Miriam for her dedicated work in editing
the research report. To my colleages Mahmood and Wan Shahrazat. I really
appreciate both of you for giving me the immediate assistance with SEM analysis
during the very final stage of my writing.
To all the participants of the community study and clinical study who have
shared their valuable life experiences with me, your heart-felt contributions will be
well remembered.
Last but not least, I adore the special people in my life; my beloved husband,
Inan, and my children, Azam, Lina, Wati and Ami, who have given me the emotional
support and understanding I needed. I have neglected my commitment towards them.
Nevertheless, they did not make me feel guilty for not providing the quality time and
space which they needed from me.
To all those who have helped me in some way or other your names have not
been mentioned here, may Allah bless you and your family with a safe journey and
happiness in this present life and after.
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TABLE OF CONTENTS
Abstract ...................................................................................................................... ii Abstract in Arabic ...................................................................................................... iii Approval Page ............................................................................................................ iv Declaration Page ........................................................................................................ v Copy Right Page ........................................................................................................ vi Dedication Page ......................................................................................................... vii Acknowledgment Page .............................................................................................. viii List of Tables ............................................................................................................. xii List of Figures ............................................................................................................ xiii CHAPTER1: INTRODUCTION ............................................................................ 1
Prevalence of Depression ............................................................................... 2 Depression in Women .................................................................................... .7 Justification of the Study ................................................................................ 11 Theoretical Framework of the Study .............................................................. 14 Conceptual and Operational Definitions ........................................................ 17
CHAPTER 2: CLASSIFICATION, DIAGNOSIS, ASSESSMENT ................... 21
Classification and Diagnosis of Depression ................................................... 21 Criteria of Major Depression .......................................................................... 23 Criteria of Dysthymia ..................................................................................... 24 Other Depression Diagnoses .......................................................................... 25 Assessment of Depression .............................................................................. 26 Theories and Models of Depression ............................................................... 27 Biological Models of Depression ................................................................... 27 The Psychological Models of Depression ...................................................... 29
CHAPTER 3 : LITERATURE REVIEW .............................................................. 36
Factors Associated with Depression In Women ............................................. 36 Biological Factors ........................................................................................... 36 Psychological and Social Factors ................................................................... 38 Past Depression and Current Depression ........................................................ 44 Personality and Depression ............................................................................ 45 Socio-Demographic Factors ........................................................................... 48 Depression in Young Women ......................................................................... 52 Combination of Factors in Depression Study ................................................. 55 Socio-Cultural Factors and Depression .......................................................... 57 Objectives of the Study .................................................................................. 62 Hypotheses of the Study ................................................................................. 63
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CHAPTER 4 : RESEARCH METHOD ............................................................... 66 Respondents ................................................................................................... 66 Procedure ........................................................................................................ 68 Training of Interviewers ................................................................................. 68 Pilot Study ...................................................................................................... 68 Interview Procedures ...................................................................................... 70 Questionnaires ................................................................................................ 72 Questionnaire for Stage One Interview .......................................................... 72 Questionnaire for Stage two Interview ........................................................... 79 Treatment of Data ........................................................................................... 82
CHAPTER 5: RESULTS ........................................................................................ 87
Socio-Demographic Characteristics of Rural and Urban Women .................. 87 Prevalence of Depression ............................................................................... 94 The Rate of Depression by Community Setting ............................................. 94 The Rate of Depression by Marital Status ...................................................... 95 The Rate of Depression by Employment Status ............................................ 96 Relationship Between Demographic Variables, Risk Factors, and Current Depression……………………………………………………………………98 Predictors of the Rate of Current Depression ................................................. 102 Analyses of the Mediating Variables .............................................................. 108 Analyses of Alternative Models ..................................................................... 111 Test- of- Goodness of Model 1 ....................................................................... 111 Test- of- Goodness of Model 2 ....................................................................... 115 Overall Findings of the Study ........................................................................ 120
CHAPTER 6: DISCUSSION, IMPLICATIONS AND RECOMMENDATIONS
Discussion and Implications of the Study ...................................................... 122 Prevalence of Depression Among Malay women .......................................... 122 Socio-Demographic Factors associated with Depression ............................... 125 Socio-Demographic Predictors of Depression ............................................... 126 Socio-Psychological Risk Factors of Depression ........................................... 127 Culture and Depression in Malay Women ..................................................... 131 Limitations ...................................................................................................... 133 Recommendations .......................................................................................... 135 Conclusion ...................................................................................................... 138
BIBLIOGRAPHY .................................................................................................... 141 APPENDIX 1 : SURVEY DOCUMENTS FOR COMMUNITY STUDY .......... 156 APPENDIX 2 : SUPPLEMENTARY STUDY ...................................................... 178
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LIST OF TABLES
Table No. Page No. 2.1 Diagnostic Criteria for Major Depression in DSM-IV 26 2.2 Diagnostic Criteria for Dysthymia in DSM-IV 28 5.1 Sample Sizes by Community Setting 87
5.2 Mean Age and Income of Respondents by Community Setting 88
5.3 Socio-demographic Characteristics of Respondents by Community Setting 89 5.4 Prevalence of Depression by Community Setting 95 5.5 Prevalence of Depression by Marital Status 96 5.6 Prevalence of Depression by Employment Status 97 5.7 Intercorrelation between Variables 99 5.8 Hierarchical Regression Analysis Predicting Current Depression 103 5.9 Hierarchical Regression Analysis in Relation to Current Depression 107 5.10 Correlations between Early Risk Factors, Mediating Variables 109 and Current Depression 5.11 Path Analysis of Early Risk Factors, Mediating Factors and Current Depression 110 5.12 Assessment of Normality for Model 112 5.13 Standardised Parameters Estimates of Model 1 114
5.14 Goodness-of-fit Indices of Model 1 115 5.15 Assessment of Normality for Data in Model 2 116 5.16 Goodness-of-fit Indices and of Model 2 118
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LIST OF FIGURES
Figure No. PageNo.
1.1 The Conceptual Model of Depression in Turner and Butler (2003 14 1.2 Conceptual Model of the Risk Factors of Depression in Women 17
5.1 Distribution of Rural and Urban Women by Marital Status 90 5.2 Distribution of Rural and Urban Women by Employment Status 91 5.3 Distribution of Rural and Urban Women by Education Level 92 5.4 Distribution of Rural and Urban Women by Health Status 93 5.5 The Relationship between Age and Current Depression 106 5.6 Effects of Early Risk Factors and Mediating Factors 111 on Current Depression 5.7 Relationship between Risk Factors and Depression in Model 1 113 5.8 Relationship between Risk Factors and Depression in Model 2 117
1
CHAPTER 1
INTRODUCTION Depression is a term generally used to describe deep sadness or bitterness experienced
by an individual. Most people experience this state of emotion while going through
stressful life events such as grieving over the loss of their loved ones or failures in
their lives. Normally, these feelings will lessen gradually over time. Sometimes an
individual experiences these emotional downs without any apparent reason for a
fleeting moment. These feelings are considered normal. However, if these feelings
deepen and persist over a period of longer than two weeks, affecting the person’s
functioning and physical state, the feelings may be a symptom of a depressive illness
(American Psychiatric Association: DSM-IV, 1994; Smith, 1995).
Depressive symptoms exist on a continuum and may occur recurrently,
affecting an individual’s functioning in life. It is important to distinguish depressive
disorder from the more ordinary fluctuations in emotions in order to assess the
severity of the depressive illness and to formulate an effective treatment plan.
Depression may occur independently of any other identified disorder or it can occur in
association with other forms of psychopathology such as psychosis, substance-related
disorder and anxiety disorder. Therefore it is important to consider the severity of
depressive symptoms and the possible association with other mental illness in the
assessing a depressive illness (American Psychiatric Association, DSM-IV, 1994;
National Alliance on Mental Illness, 2006).
Depressive symptoms can be divided into four domains; namely, affective,
cognitive behavioural and physical functioning. The affective symptoms are usually
manifested by sadness, emptiness, low motivation and loss of interest or pleasure in
2
enjoyable activities such as recreation, social interaction, and sexual activity.
Cognitive symptoms include negative thoughts about oneself, the world, the future
and others. Among the negative self-evaluations, which are commonly expressed by
depressed individuals, are incompetence, unworthiness, hopelessness, helplessness
and unacceptability by others. Difficulty in concentration and inability in making
decisions and memorising are the frequent problems reported by depressed people.
The affective and cognitive changes may result in observable behaviours such as
withdrawing from social activities. In cases of more severe depression, a depressed
person may stay in bed for a prolonged period of time. Psychomotor movements
including walking and speech are slowed down. Depression may also result in
reduction in energy, loss in appetite, and excessive or lack of sleep (Bhatia & Bhatia,
1999; Hammen, 1997).
Depressive symptoms vary in degree and duration, and these symptoms may
occur independently or concurrently with other mental illness. The symptoms are
observable in their cognitive, affective and physical changes. Therfore, it is important
to consider these factors in the assessment of a depressive illness.
PREVALENCE OF DEPRESSION The estimated frequencies of a certain disorder in a population are expressed as
prevalence. Prevalence of depression refers to the incidence of depression in a
community measured using a standard assessment method. The prevalence of
depression is normally derived from epidemiological studies conducted on a defined
population group. Lifetime major depression is the most common measure of
depression in most epidemiological studies.
3
The National Institute of Mental Health (2006) reported that major
depression is the leading cause of disability in the United States among those aged 15
to 44 years, affecting approximately 14.8 million American adults. This accounts for
about 6.7% of the population aged 18 and above. According to the World Health
Organization estimate, by the year 2020, depression will be the second leading cause
of disability worldwide
A study comparing prevalent statistics between 1991 to 1992 period and 2001
to 2002 period collected from two surveys of US sample population (n>40,000 per
sample) found that the prevalence of major depression has more than doubled within
these two periods from 3.3% to 7.0% (Compton, Conway, Stinson, Grant & Grant,
2006). Recent epidemiological studies reported a considerable increase in the rate of
lifetime major depression with 13.2% in the United States (Hasin, Goodwin, Stinson
& Grant, 2005), and 16.0% in New Zealand (Oakley-Brown, Wells, Scott & McGee,
2006). In general, it is noted that the prevalence rate of depression increases overtime
and varies considerably between countries and community settings.
Two most frequently cited studies reporting the prevalence of depression are
the Epidemiologic Catchments Area (ECA) study (Regier & Robins, 1991) and the
National Comorbidity Survey (NCS) by Kessler, McGonagle, Nelson, Hughes, Swartz
and Blazer (1994). According to the ECA study, using the Diagnostic Interview
Schedule (DIS) on a population size of 20,000 United States population aged above 18
years, nearly 23.5% men and 35.7% women reported experiencing depressive
symptoms or dysphoria for more than two weeks sometime in their life. About 3.6%
men and 8.7% women met the diagnostic criteria for lifetime major depression.
About 2.2% men and 4.1% women reported experiencing dysthymia at one point in
life (Weissman, Bruce, Leaf, Florio & Hazler, 1991). The NCS study was conducted
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on a probability-based sample of 8098 United States population between the ages of
15 and 54 using a modified version of the Composite International Diagnostic
Interview (CIDI) incorporating the criteria in Diagnostic and Statistical Manual of
Mental Disorders (DSM-III). The prevalence of lifetime major depression was 12.7%
in men and 21.3% in women while the prevalence of lifetime dysthymia was 4.8% in
men and 8.0% in women (Kessler et al., 1994). These statistics support the higher rate
of depression in women reported in past studies.
Women experience depression twice as often as men. The ratio of 2:1 in
depression between women and men has been consistent between different
epidemiological studies over time (Bebbington, Dunn, Jenkin, Lewis, Brugha, Farell,
& Meltzer, 1998). Surveys on clinical and general population show consistent results.
Over the course of a lifetime, depression occurs in approximately 20% of women
compared with 10% of men. The National Institute of Mental Health (NIMH) study
in 1980 shows a lifetime depression of 10.2% in the general population, of which 70%
are women and 30% men (Nolen-Hoeksema, 1990). A meta-analysis of gender
differences in depression from six European epidemiological studies of 38,434 men
and 40,024 women reported similar women to men ratio for the six months’
prevalence with 14.91% women and 7.6% men (Angst, Gamma, Gastpar, Lepine,
Mendlewicz & Tylee, 2002). This finding seems to be consistent in studies over time
in different western and non-western countries of the world including United States,
Taiwan, Japan and Italy (Angst et al., 2002; Bebbington et al., 1998; Craighead &
Nemeroff, 2004; De Girolamo et al., 2006). Although the prevalence rate varies
between countries but the women to men ratio of depression is consistent between
countries and over time.
5
Studies of depression in women have also indicated that the rate of
depression varies between ethnic groups, with higher risk observed in women with
low socio-economic status. The Study of Women’s Health across the Nation (SWAN)
conducted in the United States on the prevalence of depressive symptoms in 3015
middle-aged women from different ethnic groups, using the Centre for Epidemiologic
Studies-Depression (CESD) Scale, reported 24% rate of clinically significant
depressive symptoms. The study observed significant variations in the prevalence of
depression with the highest rates among Hispanics (42.97%) and African-Americans
(27.44%), and the lowest among Chinese (14.3%) and Japanese (14.1%) (Bromberger,
Harlow & Kravitz, 2003). Prevalence of depression was associated with younger age,
lower levels of education and financial difficulties. All health-related variables were
significantly associated with depression in the expected direction; higher rates among
women with poor perceived health, lower social support and higher stress levels.
Beckman, Copeland and Prince (1999) conducted a meta-analysis of 34 community
studies on the prevalence of depression in later life. Studies with samples of more
than 200 participants aged 55 years or older from western and non-western countries
reported prevalence rate of depression ranging from 0.4% to 35%. While major
depression is rare among the elderly, there was consistent evidence, however, of
higher prevalence among older people with socio-economic difficulties. In general
these studies reported higher prevalence of depression in women than men, and socio-
economic status factor may influence these rates of depression.
6
Prevalence of Depression in Malaysia
Although studies on depression have been widely conducted in the western world,
literature on the study of depression in Malaysia is rather limited. Few community
studies on depression have been reported. According to Varma and Azhar (1995), the
most common psychiatric symptoms observed in patients and families who attended
the primary health care facilities in Malaysia is depression (13.2%), followed by
hypochondriac symptoms (8.2%) and anxiety (6.1%).
According to the survey on psychiatric morbidity in Malaysian adults in 1996
(Maniam, Ding, Lim, Toh, Aziz et al., 1997), using the General Health Questionnaire
(GHQ-12) administered to 35,733 respondents aged 16 years and above, depression
and anxiety were the main psychological symptoms reported. The estimated
prevalence of emotional disorders was higher in women (10.5%) as compared to men
(8.5%), with higher rates reported in Negeri Sembilan and other states in East
Peninsular including Pahang, Kelantan, Trengganu, and Kelantan and Sabah. The
highest rate was reported among widows (29.1%) and divorcees (20.5%). Although
GHQ-12 is a general measure of mental and emotional health of an individual, these
indices reflect the rate of depression in the community to a certain extent since some
of the items in GHQ-12 measure symptoms of depression such as the state of sadness,
unhappiness, worthlessness, inability to concentrate and sleep difficulties. Analysis of
GHQ-12 by items indicated that “feeling unhappy and depressed” was reported by
11.8% of the respondents, and it may reflect the rate of depression in Malaysian
community. However, most epidemiological studies in other countries reported more
specific measures of depression such as current and lifetime depressive episode, major
depression and dysthymia (Kaelber, Moul & Farmer, 1995).
7
Despite the lack of statistics on the epidemiology of depression in Malaysia,
particularly among women, there is evidence that depression is prevalent in the
community but not treated in the primary health care institutions. Azhar (2001)
believed that physicians in Malaysian primary health care institutions did not detect
depressive disorders in the majority of patients since patients tended to report physical
symptoms instead. The reluctance or inability of the patients to report psychological
symptoms may be due to cultural factors. The symptoms of depression normally
reflect the weaknesses or abnormality of the person that is considered socially
undesirable. According to the author, some sectors of Malaysian society tend to relate
certain depressive symptoms to spiritual disturbances, and to alleviate their sufferings,
they may prefer to consult the traditional faith healer (bomoh) rather than seek
professional help. As a result, the primary health care institutions are likely to
underreport the number of people experiencing depression in the Malaysian
community. Therefore, there is a need to study the prevalence of depression in women
in Malaysia.
DEPRESSION IN WOMEN
Depression in women has commonly been associated with the biological differences
between male and female. Gender differences between women and men in the rate of
depression emerge when females enter puberty. The differences in prevalence of
depression remain high throughout the child-bearing years and into late middle age.
Hormonal factors seem to play a role in some of the mood disturbances experienced
by women. About 20% to 40% of menstruating women experience mood
disturbances, while 2% to 10% of these women experience premenstrual dysphoric
disorder with severely impaired behaviour (Hammen, 1997). Biological differences
8
between men and women in thyroid function, circadian rhythm pattern (the system
that regulates sleep) and the activity of neurotransmitters including serotonin and the
effect of estrogens on these neurotransmitters may contribute to gender disparity in the
prevalence of mood disorder (National Alliance on Mental Health, 2006).
The physiological changes associated with female reproductive function might
be responsible for the higher prevalence rate in women. The effect of female gonodal
steroids on neurotransmitters such as serotonin may result in higher prevalence of
depression in women (Bhatia & Bhatia, 1999). However, studies of women seeking
treatment of menstrual problems have found that women with severe premenstrual
problems, who tended to have lifetime history of major depression and other
psychiatric disorders, do not indicate that hormonal changes constitute the sole cause
of major depression. Similarly, an epidemiological study on menopausal period
indicates that hormonal changes in menopause are not the sole cause for the higher
rate of depression in women (Gotlib & Hammen, 2002; Hammen, 1997). There is
also some evidence that postpartum period is associated with increase in thyroid
hormonal changes which might explain depressive symptoms in postpartum women.
However, women developing postpartum depression are more likely to have personal
and family history of depression, stressful life events and other psychosocial factors
implying the possible effects of a combination of physiological, psychological and
social factors (O’Hara, Schlechte, Lewis, & Varner, 1991 cited in Hammen, 1997;
Henshaw, 2003).
Studies indicated that genetic factors may also contribute to the differences
among people in the development of depressive disorders. Twin studies of depressive
disorders suggest a concordance rate of about 60% for identical twins and 15% for
fraternal twins, whether they are reared together or apart. However, the concordance
9
rate for bipolar depression tends to be higher than that for unipolar depression
(Hammen, 1997; McGuffin, Katz, Watkins & Rutherford, 1996). Susic (2006)
reported that various twin studies estimate the overall heritability rate for major
depression of about 39%, indicating some biological predisposition but reflecting
other more prominent social and environmental factors
According to Piccinelli and Wilkinson (2000), biological factors may to some
extent accentuate gender differences with female preponderance to depressive
disorders. However, the authors observed that socio-cultural related to life events and
coping skills contribute to the gender differences in prevalence of depression. One of
the socio-cultural factors associated with the gender differences is the perceived social
roles of women. The perceived social roles of women are believed to influence the
higher rate of depression in women. Stenius, Veysey, and Hamilton (2005), in their
findings on the effect of social roles in the recovery process of mentally-ill women,
concluded that valued social roles helped in the recovery process by improving their
self-esteem, confidence and happiness, while devalued social roles contributed to
depression. Similarly, Nolen-Hoeksema (1990) observed that among the Amish
community where the mothering role is highly valued and perceived to be on par with
male economic activities that support families, there is no gender difference in
depression. These studies indicated that the perceived social roles and homemaking
roles of women may to some extent contribute to the gender differences in depression.
In relation to the socio-cultural role of women, the femininity trait of women is
believed to contribute to the gender differences in the prevalence of depression.
Stoppard (2000) suggested a woman-centred approach in understanding depression in
women. The approach is based on two assumptions related to women’s personality.
Firstly, the femininity trait in women is believed to increase susceptibility to
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depression. The prominent feminine trait in women could be due to physiological
differences or socially learnt behaviours. Secondly, the high need for relatedness with
others in women’s development of the self will result in depression when this
intimacy need is impaired in a core relationship such as marriage. According to the
author, in a culture which devalues the social roles of homemaking, nurturing and
caring for others, women’s self-esteem is adversely affected, contributing to the
higher risk of depression.
Beside the influence of biological and social role on depression in women,
socio-economic status (SES) variables such as income, employment and education
level are found to be significantly associated with depression. Summary of findings
from several epidemiologic studies of major depression noted strong relationship
between SES and depression. Review of major studies conducted in African and
Asian countries identified low SES and poverty as risk factors for major depression
(Saraceno, Levav, & Kohn, 2005). Economic stressors are likely to result in increased
level of depression. It has been shown that the combination of low socio-economic
status including poverty and low education level results in increased strains and stress,
thus compounding the negative mental health effects on women as compared to men
(Brems, 1995; Hammen, 1997; Riolo, Nguyen, & King, 2005). Therefore, a study on
risk factors of depression among women of low SES could provide further
understanding on other compounding factors which result in depression in women.
Past studies indicated that the biological, socio-cultural and socio-economic
status contributed to the consistently higher prevalence of depression in women than
men. The possibility that the differences might be due to methodological confounding
has been explored. However, it was concluded that these factors are not of sufficient
magnitude to explain the gender differences (Kaelber et al., 1995). Overall, there is