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Epidemiological study of the prevalence of depressive disorders in primary health care in Morocco

Objective: To determine the prevalence and the impact of depressive disorders in primary health care and its associated factors. Methodology: It’s a cross‐sectional study with 351 participants selected from Moroccan primary care facilities, aged above 18 years without chronic somatic or psychiatric disease. The participants answered a questionnaire that included demographic characteristics, the Mini International Neuropsychiatric Interview for major depressive episode (MDE), dysthymic disorder and the Global Assessment of Functioning (GAF). Statistical analysis was performed by the SPSS 13.0 software. Results: The prevalence of depressive disorders in the sample was 13.7%, that of MDE was 9.1%, while dysthymic disorder was 4.3%, the rate of recurrent depressive episodes was 38.2% (6% of participants), and the prevalence of depression over a lifetime was 17.7%. The percentage of depression was higher among women than men (P = 0.01). 6.3% of depressed patients have already attempted to suicide. Analysis of GAF scores showed an average of 76.2 ± 24, a lower score was significantly found among patients with current MDE (P = 0.001), dysthymic subjects (P = 0.001) and those who suffer from recurrent MDE (P = 0.001). Depressive disorders in univariate analysis were associated with: Female gender P = 0.01 odds ratio (OR) 2.1 (1.09–4.3), unemployment P = 0.02 OR 0.4 (0.2–0.9), and childbearing age P = 0.004 OR 3.5 (1.5–8). Adjusted OR has not demonstrated a significant association. Conclusion: The high prevalence of depressive disorders, suicide risk, and the alteration of the quality of life among primary health care patients in Morocco suggest the importance of identifying and treating this population.

The sample size was calculated using the following formula:

N = 1,96² p. (1-p)/margin of error²
With: • p: The expected proportion of subjects presented a depression • Margin error: Between 0,03² and 0.05² The patients must be aged 18 years old or more. We excluded subjects who were treated for a psychiatric disorder and/or chronic and disabling physical illness such as diabetes, endocrine disorders, neurological disorders, cancer, and others. We also excluded the subjects who refused to participate in the study, and those who have not given their verbal consent.
Data collection was carried out by psychiatrist and physicians who received psychiatric training for the Mini International Neuropsychiatric Interview (MINI). It was conducted using a standardized questionnaire with two parts.
The first part assesses the demographic characteristics of consultants; the socioeconomic level of the participants; and physiological status of women. To determine the socioeconomic level of the participants, we used the scale "The Problems Meeting Basic Needs," which include five items specifying, in the last 30 days, if the participants met with serious problems regarding basic specified encompassing food, transportation, finance, shelter, and clothing. [8] Among women, we specified the childbearing status.
The second part used the MINI, to assess major depressive episode (MDE) (current and anterior), depressive episode with melancholic features, dysthymic disorder, and suicide risk. The MINI has been translated and validated in Moroccan dialect; [9] the validity study demonstrated a satisfactory quantitative assessment of the value of kappa >0.8. We assessed also the quality of life by "Global Assessment of Functioning" (GAF) which is a numerical scale (from 0 to 100) used to evaluate the psychological, social and professional performances of an individual. The research communities affirmed that the reliability of the scale GAF is good specifically when it is used in patients with a mood disorder. [10] The time spent to evaluate each participant by the questionnaire was 30 min.

Statistical analysis Statistical analysis was performed by The Statistical
Package for the Social Sciences (SPSS) version 13.0 software provided by the laboratory of Biostatistics, faculty of medicine Rabat. A descriptive analysis of the different parameters was made. Quantitative variables were described as a means ± standard deviation and categorical variables were expressed as percentages. A search for factors associated with depressive disorders was made using the Chi-square test or Student's t-test. Then logistic regression was used to take into account possible confounding factor. A P < 0.05 was considered significant.
The prevalence of depressive disorders was 13.7%, MDE and dysthymia are more common among women than men (P = 0.0001, P = 0.05, respectively) [ Table 2].
The melancholic features were found among 22, 6% of depressive patients and 6.3% of these patients have already attempted to suicide.  The prevalence of MDE in men who have attempted to suicide was 16.7% versus 2.8% among women without a statistically significant difference (P = 0, 2).
Results of the general GAF score showed an average of 76.25 ± 24, a lower score was found in patients with current MDE (P = 0.0001), dysthymic subjects (P = 0.0001) and those who suffered from recurrent MDE (P = 0.0001) [ Table 3].

Discussion
Depressive disorders have a negative influence on the quality of life of patients and their professional competence. [11,12] This disease also is known by its suicide risk. Indeed, 16% of depressed patients died by suicide. [13,14] In clinical practice, the first contact with these patients will be at the primary care. [15] However, identifying patients with depressive symptoms can be difficult for the primary care physicians due to the diversity of depressive spectrum. [16,17] Our study showed that depressive disorders are common in primary care, and depressed patients have a disrupted social and professional functioning.
According to our results, 13.7% of patients in primary care meet the criteria of Diagnostic and Statistical Manual of Mental Disorders IV of depressive disorders. This prevalence is lower than that found in other studies where the prevalence was between 22.6% and 30.3%. [18][19][20] In the present study, 9.1% of patients had an MDE, a prevalence lower than that some previous studies, [1,21] but much higher than others conducted in the general population. [3,[22][23][24] Such disparity can be explained by the difference in methodological assessment of depressive disorders.
In addition, 4.3% subjects screened had a dysthymia, a rate similar to that found in Spanish study. [25] Analysis of data confirmed the high rate of prevalence of lifetime of depression (17.7%) this seems closer to the results of two American studies. [22,26] A gender difference in the prevalence of depressive disorders was observed P = 0.01 OR 2.1 (1.09-4.3). In fact, women have a higher rate of MDE and dysthymia compared to men; which consistent with the literature. [27] Our finding indicated that the GAF score was statistically significant lower among patients with depressive disorders, specifically patients with MDE and recurrent MDE. In a cross-sectional study evaluated the quality of life among 360 depressed patients; [28] they found that the score is altered in all its physical and mental dimensions. A second study, [29] carried out in China revealed that < 3% of depressed outpatients are satisfied with their health.
Other studies and meta-analysis showed that depressive disorders are an important determinant of disability and quality of life in patients. [30,31] On multivariate analysis, we did not find a significant association this can be explained by the sample size, which was relatively smaller than that of other studies. Although it has been demonstrated that MDE was associated with female gender, substance use, unmarried status, and being unemployed. [23,32]

Conclusion
The prevalence of depressive disorders, suicide risk, and the alteration of the quality of life among primary health care patients in Morocco, suggest the importance of identifying and treating this population, which implies the physician awareness of those disorders.

Financial support and sponsorship
Nil.