Background
Neuro-psychiatric disorders, particularly high level of anxiety and depressive symptoms have received a growing attention due to their burden on quality of life [
1,
2], service satisfaction [
1,
3‐
6], medication adherence and treatment outcomes [
2,
7] and impact on functionality among patients with general medical conditions at primary health care settings [
8,
9]. Moreover, the proportion of high level of anxiety and depressive symptoms are very common among patients with general medical conditions in low- and high-income countries [
7,
8,
10‐
16]. In Ethiopia, anxiety and depressive symptoms are reported up to 63.7% in patients with general medical condition and up to 10.8% in the community residents [
17‐
19]. And demographic [
20]; psychosocial [
21,
22]; clinical [
13,
14]; and behavioral factors were commonly reported as a risk factors of high level anxiety and depressive symptoms in previous studies [
7,
13].
There is a high level of medically unexplained psychosomatic symptoms in non-psychiatric setting [
23] whereas treating these somatic symptoms found to increase the recovery rate and improve functionality of patients with general medical conditions [
24]. However, there is limited evidence on prevalence of high-level anxiety and depressive symptoms in patients with general medical conditions at non-psychiatric settings (health center) and in the community residents in Ethiopia, a country whose substantial health care service has been delivered at primary health care level (currently, a non-psychiatric settings). The main reason why we conduct this comparison study is to see the level and difference of anxiety and depressive symptoms among patients with general medical conditions at health center (a non-psychiatric setting) and community residents. We believe that such local epidemiological evidence is very important to develop the WHO recommended country-specific polices [
25] such as to prioritize common mental health problems, to overcome the large shortage of mental health-care services throughout the country, to develop strategies that help to decrease anxiety or depression-related mortality and morbidity, and to plan integration of mental health service in primary health care system in resource limited countries like Ethiopia. Therefore, the aim of this study was to assess the prevalence and associated factors of anxiety and depressive symptoms among patients with general medical conditions at health center and community residents.
Results
Response rate
A total of 3988 participants were completed the study with 95.5% response rate. From the total 4176 potential participants, 3988 had completed the interview (1363 from medical care visitors, and 2625 from community residents); however, 63 refused, 61 failed to complete the interview, and 64 were excluded due to the exclusion criteria.
From total participants, 1984/3988 (49.7%) of the participants were males (which composes 1271 (64.1%) from community and 713 (35.9%) from health center). The median and mean age was 34 and 35.38 (SD = 12.82) years, respectively for community sample while the median and mean age of health center samples was 32 and 35.37 (SD = 14.07) years old, respectively. See Table
1 for more details.
Table 1
Socio-demographic characteristics of participants
Sex | | | | .02 | 5.4 |
Male | 1984 (49.7) | 1271 (64.1) | 713 (35.9) | | |
Female | 2004 (50.3) | 1354 (67.6) | 650 (32.4) | | |
Living area | | | | <.001 | 367 |
Urban | 2916 (73.1) | 2174 (74.6) | 742 (25.4) | | |
Rural | 1072 (26.9) | 451 (42.1) | 621 (57.9) | | |
Living circumstance | | | | =.001 | 10.3 |
Alone | 243 (6.1) | 183 (75.3) | 60 (24.7) | | |
With family | 3745 (93.9) | 2442 (65.2) | 1303 (34.8) | | |
Age | | | | .007 | 12 |
18–24 | 972 (24.4) | 617 (63.5) | 355 (36.5) | | |
25–34 | 1170 (29.3) | 795 (67.9) | 375 (32.1) | | |
35–44 | 888 (22.3) | 611 (68.8) | 277 (31.2) | | |
≥ 45 years | 958 (24.0) | 602 (62.8) | 356 (37.2) | | |
Current marital status | | | | .04 | 10.1 |
Single | 1295 (32.5) | 841 (64.9) | 454 (35.1) | | |
Married | 2388 (59.9) | 1599 (67.0) | 789 (33.0) | | |
Othersa | 305 (7.6) | 185 (60.7) | 120 (39.3) | | |
Relative wealth | | | | .32 | 2.3 |
Lower | 1021 (25.6) | 673 (65.9) | 348 (34.1) | | |
Same | 2861 (71.7) | 1875 (65.9) | 986 (34.5) | | |
Better | 106 (2.7) | 77 (72.6) | 29 (27.4) | | |
Family size | | | | .001 | 13.2 |
1 to 2 | 672 (16.9) | 483 (71.9) | 189 (28.1) | | |
3 to 4 | 1552 (38.9) | 1006 (64.8) | 546 (35.2) | | |
5 and more | 1764 (44.2) | 1136 (64.4) | 628 (35.6) | | |
Clinical, substance use, lifestyle and psychological factors
From the participants who had visited for medical attention; 235/1363 (17.2%) was diagnosis for hypertension, 184/1363 (13.5%) for diabetes, 340/1363 (24.9%) for HIV/AIDS, 136/1363 (10.0%) for surgical cases, 55/1363 (4.0%) for mental illness, and 413/1363 (30.3%) for other medical conditions. Two-third of the health center sample, 1022/1363 (75.0%) had more than one-year morbidity. Current alcohol use was 739/2625 (28.2%) in community participants while 330/1363 (24.2%) in health center participants. In terms of life style, 746/2625 (28.42%) of the community sample were engaged in regular physical exercise whereas 260/1363 (19.1%) of participants in health center were engaged in regular physical exercise.
A higher proportion of childhood physical abuse (before the age of 18 years old) was reported in community samples, 1323/2625 (50.4%) than participants in health center, 637/1363 (46.7%), see Table
2.
Table 2
Psychosocial and behavioral characteristics of participants
Regular exercises | Yes | 746 (74.2) | 260 (25.8) | <.001 | 30.288 |
No | 1879 (63.0) | 1103 (37.0) |
Fruits & vegetables in regular meal | Yes | 1920 (64.4) | 1060 (35.6) | .001 | 10.169 |
No | 705 (69.9) | 303 (30.1) |
Social support | Low | 395 (69.8) | 171 (30.2) | .001 | 13.063 |
Average | 1809 (64.1) | 1014 (35.9) |
Good | 421 (70.3) | 178 (29.7) |
Depression | Yes | 132 (49.1) | 137 (50.9) | <.0001 | 35.982 |
No | 2493 (67.0) | 1226 (33.0) |
Use of public health insurance | Yes | 1308 (60.5) | 854 (39.5) | <.0001 | 59.470 |
No | 1317 (72.1) | 509 (27.9) |
Feeling stigmatized | Yes | 283 (72.6) | 107 (27.4) | .003 | 8.733 |
No | 2342 (65.1) | 1256 (34.9) |
Physical/verbal abuse | Yes | 1323 (67.5) | 637 (32.5) | .028 | 4.821 |
No | 1302 (64.2) | 726 (35.8) |
Alcohol use | Yes | 739 (69.1) | 330 (30.9) | .008 | 7.102 |
No | 1886 (64.6) | 1033 (35.4) |
Smoking | Yes | 131 (72.4) | 50 (27.6) | .057 | 3.619 |
No | 2494 (65.5) | 1313 (34.5) |
Khat chewing | Yes | 133 (83.6) | 26 (16.4) | < .0001 | 23.372 |
No | 2491 (65.1) | 1336 (34.9) |
Cannabis use | Yes | 13 (72.2) | 5 (27.8) | | |
No | 1611 (65.8) | 1357 (34.2) |
Prevalence of high-level of anxiety and depressive symptoms (n = 3988)
High-level of anxiety and depressive symptoms were found to be 8.8% (351/3988) with 95% CI; 8.0%–10.0% and 6.7% (269/3988) with 95% CI 6.0%–8.0% among total participants, respectively.
High-level of anxiety symptoms was 12.6% with 95% CI; 11.0%–14.0% among participants with general medical conditions which is significantly higher than participant from the community, 6.8% with 95% CI; 6.0%–8.0% at (
P < .0001). High-level of depressive symptoms was 10.1% with 95% CI; 8.0%–12.0% among participants with general medical conditions which is significantly higher than participant from the community, 5.0% with 95% CI; 4.0%–6.0% at (
P < .0001). The proportion of high-level anxiety and depressive symptoms in relation to common biopsychosocial variables is reported among participants in community and health center (Table
3).
Table 3
Proportion of high-level anxiety and depressive symptoms in relation to common psychosocial variables among participants
Sex |
Male | 128 (6.5) | 168 (8.5) | 1271 (64.1) | 713 (35.9) |
Female | 141 (7.0) | 183 (9.1) | 1354 (67.6) | 650 (32.4) |
Age |
18–24 | 54 (5.6) | 74 (7.6) | 617 (23.5) | 355 (26.0) |
25–34 | 49 (4.2) | 68 (5.8) | 795 (30.3) | 375 (32.1) |
35–44 | 65 (7.3) | 78 (8.8) | 611 (23.3) | 277 (31.2) |
45 and more | 101 (10.5) | 131 (13.7) | 602 (22.9) | 356 (37.2) |
Living area |
Urban | 198 (6.8) | 270 (9.3) | 2174 (74.6) | 742 (25.4) |
Rural | 71 (6.6) | 81 (7.6) | 451 (42.1) | 621 (57.9) |
Living circumstance |
Alone | 17 (7.0) | 29 (11.9) | 183 (7.0) | 60 (4.4) |
With family | 252 (6.7) | 322 (8.6) | 2442 (93) | 1303 (93.9) |
Relative Wealth |
Low | 105 (10.3) | 117 (11.7) | 673 (65.9) | 348 (34.1) |
Average | 152 (5.3) | 216 (7.5) | 1875 (65.5) | 986 (34.5) |
High | 12 (11.3) | 18 (17.0) | 77 (72.6) | 29 (27.4) |
Social support |
Low | 60 (10.6) | 86 (15.2) | 395 (69.8) | 171 (30.2) |
Moderate | 179 (6.3) | 219 (7.8) | 1809 (64.1) | 1014 (35.9) |
Strong | 30 (5.0) | 46 (7.7) | 421 (70.3) | 178 (29.7) |
Physical/verbal abuse |
Yes | 162 (8.3) | 232 (11.8) | 1324 (67.6) | 636 (32.4) |
No | 107 (5.3) | 119 (5.9) | 1301 (64.2) | 727 (35.8) |
Parental death at childhood |
Yes | 95 (12.6) | 53 (7.0) | 494 (65.3) | 262 (34.7) |
No | 174 (5.4) | 298 (9.2) | 2131 (65.9) | 1101 (34.1) |
Family history of mental illness |
Yes | 28 (5.4) | 74 (14.3) | 294 (56.8) | 224 (43.2) |
No | 241 (6.9) | 277 (8.0) | 2331 (67.2) | 1139 (32.8) |
Alcohol use |
Yes | 89 (8.3) | 121 (11.3) | 739 (69.1) | 330 (30.9) |
No | 180 (6.2) | 230 (7.9) | 1885 (64.6) | 1032 (35.4) |
Smoking |
Yes | 10 (5.5) | 13 (7.2) | 131 (72.4) | 50 (27.6) |
No | 259 (6.8) | 338 (8.9) | 2494 (65.5) | 1313 (34.5) |
Khat chewing |
Yes | 12 (7.5) | 25 (15.7) | 133 (83.6) | 26 (16.4) |
No | 257 (6.7) | 326 (8.5) | 2491 (65.1) | 1336 (34.9) |
Determinants of high-level anxiety symptoms in community and health center
First, in a separate analysis only for participants in community, we tested factors in relation to high-level of anxiety and found that living in urban (p = .037, AOR .588 with 95% CI .35–.97) and higher wealth (p < .001, AOR .50 with 95% CI .35–.70) were a protective factor for high-level anxiety in the community sample. However, advanced age, 45 years and above (P < .001, AOR = 2.38 with 95% CI 1.47–3.67); poor social support (P < .001, AOR = 3.77 with 95% CI 2.09–6.82); physical abuse (P < .001, AOR = 3.38 with 95% CI 2.34–4.88), and loss of parents before age of 18 years (P = 003, AOR = 2.14 with 95% CI 1.30–3.54) were risk factors for high-level anxiety among community residents.
Secondly, we also tested in a separate analysis for each factors in relation to high level of anxiety among patients with medical conditions, we found that patients who had diabetes (P = .006, AOR = 2.33, 95% CI 1.27–4.28) and other mental illnesses (P < .001, AOR = 8.32, 95% CI 3.17.77); patients who be afraid dying from their current illness (P < .001, AOR = 2.20, 95% CI 1.50–3.20); and those who are started to take medication (P = .006, AOR = 2.02, 95% CI 1.23–3.33) were a risk factors of high-level anxiety. However, living in urban (P < .001, AOR = .47, 95% CI .32–.68) was a protective factor.
Determinants of high-level depressive symptoms in community and health center
Similarly, in a separate analysis for community participants, we tested factors in relation to high-level of depressive symptoms and found a better wealth status (p < .001, AOR = .46 with 95% CI .312–.678) was a protective factor for high-level depressive symptoms in the community sample. However, age greater than 34 years (35 to 44 years (p = .038, AOR = 1.85 with 95% CI 1.03–3.32); 45 years and above (P = .001, AOR = 2.52 with 95% CI 1.45–4.37); poor social support (P = .024, AOR = 2.17 with 95% CI 1.11–4.26); physical abuse (P < .001, AOR = 2.59 with 95% CI 1.74–3.88), and loss of parents before age of 18 years (P < 001, AOR = 2.09 with 95% CI 1.40–3.12); participants who did not use health insurance (p = .001, AOR = 1.93 with 95% CI 1.31–2.85); and participants who did not do regular physical activities or exercise (p < .001, AOR = 4.36 with 95% CI 2.14–8.89) were risk factors for high-level depressive symptoms among community residents.
Again, we also tested each variable in relation to high level of depressive symptoms among patients with general medical conditions; current alcohol use (P = .001, AOR = 1.64 with 95% CI 1.12–2.40) and death of parents before the age of 18 years (P < .001, AOR = 2.21, 95% CI 1.5–3.27) were the only risk factors of high-level depressive symptoms.
Significant factors for high-level anxiety in all participants (n = 3988)
Finally, we tested all factors in relation to high-level anxiety for both (community and health center samples) and we found that advanced age, living alone, having general medical conditions, physical abuse, and family history of mental illness were positively associated with high-level of anxiety. Moderate and strong social support, loss of a parent before age of 18 years old and lower relative wealth were negatively associated (protective) with high-level anxiety (Table
4).
Table 4
Associated factors of high-level of anxiety among all participants (n = 3988)
Age |
18–24 | 74 (7.6) | 898 (92.4) | 1.00 | |
25–34 | 68 (5.8) | 1102 (94.2) | .88 (.62, 1.26) | .490 |
35–44 | 78 (8.8) | 810 (91.2) | 1.42 (.99, 2.03) | .051 |
45 and more | 131 (13.7) | 827 (86.3) | 2.03 (1.47, 2.80) | <.0001 |
Living circumstance |
Alone | 29 (11.9) | 214 (88.1) | 1.57 (1.01, 2.44) | .047 |
With family | 322 (8.6) | 3423 (91.4) | 1.00 | |
Relative Wealth |
Low | 117 (11.7) | 904 (88.5) | .45 (.26, .78) | .004 |
Average | 216 (7.5) | 2645 (92.5) | .72 (.40, 1.28) | .261 |
High | 18 (17.0) | 88 (83.0) | 1.00 | |
Social support |
Low | 86 (15.2) | 480 (84.8) | 1.00 | |
Moderate | 219 (7.8) | 2604 (92.2) | .51 (.38, .67) | <.0001 |
Strong | 46 (7.7) | 553 (92.3) | .43 (.29, .64) | <.0001 |
Sample |
Health center | 172 (12.6) | 1191 (87.4) | 2.1 (1.67, 2.64) | <.0001 |
Community | 179 (6.8) | 2446 (93.2) | 1.00 | |
Physical/verbal abuse |
Yes | 232 (11.8) | 1728 (88.2) | 2.1 (1.63, 2.65) | <.0001 |
No | 119 (5.9) | 1909 (94.1) | 1.00 | |
Parental death at childhood age |
Yes | 53 (7.0) | 703 (93.0) | .69 (.50, .94) | .02 |
No | 298 (9.2) | 2934 (90.8) | 1.00 | |
Family history of mental illness |
Yes | 74 (14.3) | 444 (85.7) | 1.67 (1.25, 2.23) | .001 |
No | 277 (8.0) | 3193 (92.0) | 1.00 | |
Significant factors for high-level of depressive symptoms in all participants (n = 3988)
All factors in relation to high-level depressive symptoms for all participants (community and health center samples) were tested in the logistic regression and we found that having general medical conditions, loss of a parent before age of 18 years old and physical abuse were positively associated (risk) with high-level of depressive symptoms. Moderate and strong social support was negatively associated (protective) with high-level depressive symptoms (Table
5).
Table 5
Associated factors of high-level of depressive symptom among all participants (n = 3988)
Age |
18–24 | 54 (5.6) | 918 (94.4) | 1.00 | |
25–34 | 49 (4.2) | 1121 (95.8) | .72 (.46, 1.14) | .157 |
35–44 | 65 (7.3) | 823 (92.7) | 1.29 (.79, 2.09) | .310 |
45 and more | 101 (10.5) | 857 (89.5) | 1.41 (.88, 2.25) | .155 |
Relative Wealth |
Low | 105 (10.3) | 916 (89.7) | .543 (.28, 1.06) | .072 |
Average | 152 (5.3) | 2709 (94.7) | .84 (.42, 1.70) | .629 |
High | 12 (11.3) | 94 (88.7) | 1.00 | |
Social support |
Low | 60 (10.6) | 506 (89.4) | 1.00 | |
Moderate | 179 (6.3) | 2644 (93.7) | .631 (.45, .88) | .006 |
Strong | 30 (5.0) | 569 (95.0) | .543 (.33, .88) | .014 |
Sample |
Health center | 137 (10.1) | 1226 (89.9) | 2.2 (1.72, 2.91) | <.0001 |
Community | 132 (5.0) | 2493 (95.0) | 1.00 | |
Physical/verbal abuse |
Yes | 162 (8.3) | 1798 (91.7) | 1.75 (1.33, 2.31) | <.0001 |
No | 107 (5.3) | 1921 (94.7) | 1.00 | |
Parental death at childhood age |
Yes | 95 (12.6) | 661 (87.4) | 2.1 (1.56, 2.77) | <.0001 |
No | 174 (5.4) | 3058 (94.6) | 1.00 | |
Alcohol use | | | .186 |
Yes | 89 (8.3) | 980 (91.7) | 1.86 (.91, 1.61) | |
No | 180 (6.2) | 2737 (93.8) | 1.00 | |
Discussion
The prevalence of high-level anxiety and depressive symptoms was found to be significantly higher in patients with general medical condition (12.6% and 10.1%) than community samples (6.8% and 5.0%) with prevalence ratio of 1.85 and 2.02, respectively. The adjusted logistic regression analysis also supports this result in which the odds high-level anxiety as well as depressive symptoms was two times among health center than community samples. Thus, high-level of anxiety and depressive symptoms might be occur as a result of the interaction of medical conditions with psychosocial issues that evidenced by risk of high anxiety and depressive symptoms among participants with general medical condition was found two times than community participants which is supported by previous studies [
17,
18,
31]. Even if it is difficult to determine the cause-effect association in this study, participants who had general medical conditions have a higher risk of high-level anxiety and depressive symptoms than community residents.
However, the current prevalence of high-level anxiety and depressive symptoms has to be found lower compared to other similar clinical studies in central Ethiopia, 17% [
8], and 18.2% in north Ethiopia [
17]. The major difference for this might be due to different in measurement tools, study population such as the current study includes all patients with any medical illnesses whereas others include patients with specific chronic disorders like diabetic, HIV, hypertension, and respiratory problems which have a potential to cause high anxiety symptoms [
7,
12‐
15]. This community prevalence also found lower than a similar community study in Ethiopia, 10.8% [
19]. The main reason for this, lifetime prevalence was assessed in previous study, and participants with starting from age 15 years were included in previous study (age limit of 18 years was in our study) which some anxiety symptoms such as separation anxiety or other neurotic disorders like phobia might be predominantly had reported in previous study age group that the current study couldn’t assessed.
Advanced age was associated with high-level of anxiety (
p < .0001), but not with high-level depressive symptoms (
p = .155) and being in the age of 45 years and above is two times risk of high-level of anxiety symptoms than being in age 18 to 24 years old. It is predictable that anxiety symptoms can always increase with age and this finding agrees with the general understanding of this trends [
20]. This is parallel to rate model study that revealed specific parts of the fear/anxiety circuit (amygdala, hippocampus and hypothalamus) in the brain undergo diverse age-related changes in response to behavioral alteration [
32]. However, in contrast to this result, risk of anxiety symptoms decreases with increase of age due to possibility of decreased emotional responsiveness with age, increased emotional control and psychological immunization to stressful experiences [
33]. And previous Ethiopian study had also strengthen the inversely association between age and anxiety unlike the current result [
19].
Participants’ living condition has been associated with high-level of anxiety (
p = .047), but not with high-level of depressive symptoms (
p = .872) and living alone was found a risk factor of high-level of anxiety than living with once family. Social relationships or integration is crucial for better mental wellness over the life span [
34]. Of course, as a social being, human needs belonginess as a basic need to have a good social interaction or relationships. However, loneliness can poses a significant mental health problem by increasing the risk of anxiety symptoms [
35], as the current study had suggested. Loneliness may increases the chance of emerging pre-existing anxiety symptoms which is supported by similar studies [
36].
Lower wealth status negatively contributes for high- level of anxiety (
p = .004), but not for depressive symptoms (
p = .072). The lower perceived relative wealth had found a to be protective for high-level of anxiety symptoms, up to 55% than participant with higher perceived wealth status. Which is supported by some studies [
37]. Greater wealth inequality has a strong impact on the prevalence of anxiety symptoms [
38]. However, in majority of the previous studies suggested that high economic and social class can prevent the occurrence of common mental disorders including high level anxiety symptoms [
39] which is totally contradicted with our findings. Living with a good economic class has a substantial protection of high-level of anxiety symptoms [
40] whereas low level household income had found a risk for the incidence of high-level anxiety symptoms and other common mental disorders in a prospective study [
41].
High level of social support found a protective factor for both high-level of anxiety and depressive symptoms. The risk of high-level anxiety and depressive symptoms could be decrease by 49% (
p < .0001) and 37% (
p = .006) in moderate social support while it could be decrease by 57% (
p < .0001) and 46% (
p = .014) in good social support with the reference of poor social support, respectively. Good social support is very important to prevent people from high-level of anxiety and depressive symptoms, and may help people to feel confident and stability which is supported by a previous study [
21]. Prospective findings justify that strong social support protected against the incidence of sever anxiety symptoms [
42].
Physical abuse has found a strong risk factor for high-level of anxiety and depressive symptoms at (
p < .0001). Participants who had experienced a history of physical abuse had found almost two times risk of high-level of anxiety and depressive symptoms than their counterparts. Physical abusive is a strong predictor of mental illness and maladaptive life events may worsen the pre-existing anxiety and depressive symptoms or may induce these symptoms as a potential risk of [
22]. In some studies, the severe consequences of early physical abuse has evidenced as etiological risk of anxiety disorders [
43], and high level of anxiety and depressive symptoms have been reported among adults experienced childhood physical abuse [
44].
Childhood parental loss or parental lost before the age of 18 years was found as a protective factor (31%) for high-level of anxiety symptoms (
p = .02), but found as a risk factor for depressive symptoms (
p < .0001) than their counterparts. This is un usual finding, but also supported by some studies [
45]. Parental separation or parental death has a risk of wide range adulthood psychopathology, including sever anxiety and depressive symptoms [
46]. Childhood separation has a negative impact on mental wellness [
47]; and different psychosocial problems such as physical abuse, poor parental care/neglection could be common in addition to lack of good parental care opportunities [
22]. However, adverse childhood life events has not always associated with psychopathology [
45].
Participant’s family history of mental illness was found risk of high-level of anxiety symptoms (
p = .001) but not risk for depressive symptoms (
p = .194) than participants without a family history of mental illness. Of course, anxiety has a strong familial association, and those children with a family history of mental illness have a greater chance of developing high-level of anxiety symptoms than their counterparts [
48].
Though we had conducted a large-scale study among samples in community and primary health center, the study has a number of limitations. The first main limitation is as we did this research in two population groups, we didn’t match the participants with some important variables (sex or age) that could add value of the result. Secondly, it is difficult to determine the cause-effect association between medical illnesses and other associated factors with high-level of anxiety and depressive symptoms due to the nature of our study design. Thirdly, we did not include participants with specific medical disorders and also did not screen community participants for any medical condition, instead we only ask them whether they had a diagnosed medical condition or not.
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