Prevalence of depression and its associated factors among primary caregivers of patients with severe mental illness in southwest, Ethiopia

Across the world, around 450 million people suffer from mental or behavioral disorders. One person in every four will be affected by a mental illness at some stage of life [1]. Mental illnesses affect peoples of all ages, educational levels, economic statuses and cultural backgrounds. The effect of these illnesses on the caregivers of people with mental illness is substantial [2]. Around 150 million persons in the world suffer from depression at any one point in time [3]. Depression is a state of low mood and aversion to activity that can affect a person’s thoughts, behavior, feelings and sense of well-being. People with depressed mood can experience feeling of sadness, lack of interest, hopelessness, helplessness, worthlessness, guilty feeling, irritability. They may also experience suicidal ideation, sleep disturbance and loss of appetite [4]. Depression accounts for 4.3% of the global burden of disease and is among the largest single causes of disability worldwide particularly for women [5]. Based on the global burden of disease 2010, depressive disorders were the second leading cause of Years Lived with Disability (YLDs) accounting for 8.2% (5.9–10.8%) of global YLDs [6]. Patients with major depression have a 40–60% greater chance of dying prematurely than the general population [5] because depression is associated with heart diseases, cancer and diabetes mellitus [5‐7]. Caregivers of patients with neurological illnesses experience high levels of psychological distress and depression; increased rates of physical illnesses and personal, financial, family, and other social problems [8]. Depression among caregivers of patients with mental illness has been estimated to be more than two times higher than the general population [9, 10]. The burden of depression among caregivers of patients with mental illness includes disturbance in routine activities, social interaction, leisure activities and jobs. Mental illness is associated with increased physical morbidity [11‐13] and reduced quality of life among caregivers [14].

Depression among caregivers of patients with mental illness has been positively associated with younger age of the care giver and lower levels of caregivers’ education [10, 15], being assaulted by patient [16], caregivers perceived stigma [10, 11], increased number of hours spent providing care (per week), older age of the caregiver and duration of care giving [11], being non-religious [17] and having a poor social support system [18‐20]. Similarly, it has been found that increased duration of mental illness, increased number of hospitalizations are positive predictors of the experience of depression among caregivers of mentally ill patients [15]. Depression further depletes the caregiver’s own resources, increasing care costs for both the caregiver and the care recipient. When caregivers are, depressed and overwhelmed by their care giving tasks, they are more likely to suffer burnout and may make the often-agonizing decision to place their loved ones in a nursing home. Caregivers often focus on the needs of those they care for but neglect their own health needs [7]. So, depression among caregivers is a serious problem [7]. However, there are little data known about depression among primary caregivers of patients with mental illness in sub-Sahara African countries including Ethiopia. Therefore, this study is aimed at assessing depression among primary caregivers of patients with mental illness in Southwest Ethiopia.

In this cross-sectional survey of primary caregivers of patients with mental illness in Southwest Ethiopia, nearly one-fifth (19%) had depression.

The prevalence of depression found in this study (19%) was comparable to the findings of the study conducted in Buraydah Mental Health Hospital, Saudi Arabia (23.33%) [11] among those with schizophrenic disorders that used DSM IV-TR criteria to assess depression.

However, the prevalence of depression found in this study was lower than the findings of a study conducted in Egypt among female caregivers in psychiatry clinic that used DSM IV-TR criteria to assess depression (34%) [28]. This discrepancy may be due to difference in the characteristics of study participants in terms of gender. In addition, caregivers of patients with mental and physical illness were included in the study conducted in Egypt [28]. Similarly, the prevalence of depression in our study (19%) was lower than the prevalence reported from India (27.5%) [15], Sri Lanka (37.5%) [29], California USA (40%) [10], and Rhode Island USA (75%) [9]. The inconsistency between our findings and that of these four studies may be due to the difference between screening tools. While we used PHQ-9 in our study, studies conducted in California and Sri Lanka used the CES-D; and the Indian study used the MADRS. Moreover, there is strong social cohesion in Ethiopia which is a good source of social support though further investigation is needed to determine its effect on the prevalence of depression.

In our study, the prevalence of depression among female primary caregivers was higher than that of male primary caregivers (25% versus 11.3%, p = 0.004). On the other hand, even though, the prevalence of depression among female primary caregivers in our study was higher than that of the male counterparts, it was still lower than the findings of Egyptian study (34%) [28]. Moreover, in the current study, 26.3% of females were housewives, who are expected to spend more of their time in care giving at home. The prevalence of depression among primary caregivers who were housewives was higher than that of farmer primary caregivers (31% vs 13.5%, p = 0.03). In Ethiopian culture, most household chores are handled by housewives. So, the double burden of household chores and caring for the patients might have put women at more risk of developing depression. In addition, as housewives spend most of their time at home, they have prolonged contact with the patients.

The current study indicated that the prevalence of depression among primary caregivers who had never attended a place of worship was higher than that of primary caregivers who had attended a place of worship daily (35.7% vs15.4%, p = 0.01). One possible explanation for this difference may be the fact that primary caregivers who had attended a place of worship daily received emotional support from religious leaders. Primary caregivers may also receive social support at their places of worship. The effect of social support on depression among caregivers was reported in the study done in the USA [20].

In the current study, giving care for more than six hours was associated with depression among primary caregivers which agrees with the study done in Saudi Arabia [11]. Having ever attended secondary school education was negatively associated with depression among primary caregivers which agrees with the study conducted in California [10]. However, giving care for patients who had two or more episodes of suicidal attempts was positively associated with depression among primary caregivers. The odds of having depression among primary caregivers increased by 16% with a unit increment in perceived stigma in the bivariate analysis. The possible reason may be because depression has strong association with perceived stigma among caregivers of patients with mental illness as reported in other study [30].

In the multivariate logistic regression, low perceived social support, being single, giving care for more than six hours, giving care for a patient with a history of suicidal attempts and illiteracy were positively associated with depression among primary caregiver of patients with mental illness.

Since we used a cross-sectional study design, it is difficult to establish a cause-effect relationship. In addition, the tools we used to assess social support and stigma were not validated in the Ethiopian context. Nevertheless, the findings will help to inform practice and future research, specifically in Ethiopia and other developing countries.

In this study, the prevalence of depression among primary caregivers was high. This may have its own impact on the treatment outcome and prognosis of patients with mental illness. In addition, the prevalence of depression among female caregivers was higher than that of the male caregivers. Depression among primary caregivers was associated with providing care for an increased number of hours per day; low perceived social support and the patient’s suicidal attempts. Therefore, while caring for patients, screening primary caregivers of patients with mental illness and treating them accordingly, is crucial to decrease the incidence of depression. Special focus should be given to primary caregivers spending long hours for providing care, those with low perceived social support; caregivers of patients with suicidal ideation and female primary care givers.