Presentation of depression: Its relationship with stigma and sociodemographic variables in a tertiary care centre

Introduction: Symptomatology of any illness is not only the expression of a pathological process in an individual, but depends upon many factors, such as environment, socio- demographic and cultural back ground and the same thing is also applicable for depression. There are plenty of studies worldwide to support the fact that depressive patients predominantly present with somatic symptoms. Many authors pointed out the influence of culture behind this fact. But the very few highlighted an important explanatory feature of this process with substantial practical and clinical significance – that is, the role of stigma. Aims and Objectives: To identify interrelation between chief presenting complains of depressive disorder with level of stigma associated, with reference to patient’s socio economic and demographic back ground. Materials and Methods: Sixty adult patients attending psychiatry OPD for first time with Major Depressive Disorder (MDD) has been selected. Semi structured proforma for socio-demographic and clinical variables, Hamilton depression rating scale, distress questionnaire and stigma scale from the selected portion of Eplanatory Model Interview Catalogue (EMIC) were used. Results: Near about half of the patients reported pains or other somatic symptoms most frequently as the most troubling symptom whereas fewer than 20% patients reported sadness as most troubling. Somatic complaints were experienced as less stigmatizing compared to sadness; the difference in mean stigma scores were statistically significant. Stigma scores were positively correlated with depression severity. Family history of psychiatric illness was experienced as more stigmatizing along with unmarried status. Conclusion: Majority of patients with major depression reported somatic complaints as most troubling which may hinder early recognition. As stigma is positively related with depression severity it may acts as barrier to help seeking. Socio-demographic variables are unrelated with presentation of depression.


Introduction
Depressive disorders are a major public health problem now. They occur frequently, and it is likely that their prevalence will grow in the years to come due to sociodemographic changes in most countries of the world that increase the numbers of people at high risk for depressive disorders, the longer life expectancy of people with chronic illness who often suffer from depressive disorders, iatrogenic depression, and the effects of certain forms of prolonged stress. 1 Currently depressive disorder is a serious public health concern, particularly in view of the fact that recent years have seen the development of a variety of effective methods of treatment of depressive disorders. These new therapies are significant additions to the armamentarium of the psychiatrist, but what is more important are that general practitioners and other physicians can successfully apply many of them. 2 It is therefore disturbing that a large proportion of people with depressive disorders do not get treatment. The general population is unaware of the frequency and ubiquity of the disorder and does not realize that effective treatment is possible. Therefore, many do not come forward seeking help from health care services, and unfortunately even those who utilize health care services are not always appropriately treated. It is estimated that in even in developed countries nearly half of those who have depressive disorders do not come forward asking for help from their doctors, and of those who do, half remain unrecognized as suffering from depressive disorders. 1 Symptomatology of any illness is not only the expression of a pathological process in an individual, but depends upon many factors, such as environment, sociodemographic and cultural background and the same thing is also applicable for depression. A major reason for not recognizing depressive disorders is that they often present mainly as physical symptoms. In previous years, it was believed that somatic complaints characterized mainly patients from developing countries and those with little education. Today it is clear that this is not so and that somatic symptoms and complaints are frequent in all populations and in people with different degrees of education. 2 Several cultural factors complicate the identification and treatment of depression. These include the experience and communication of social and emotional problems as aches, pains, and other somatic symptoms, illustrating a process known as somatization. Failure to recognize these somatic symptoms as a presentation of depression leads to missed diagnosis and opportunities for treatment. Because the relationship between somatic symptoms and emotional symptoms is not obvious, patients may reject the diagnosis and fail to comply with recommended treatment. 2 The reasons for this trend are many. The stigma attached to mental illness makes patients reluctant to speak about their psychological problems. 2 Physicians are often reluctant to treat people with mental illness and therefore may be rather superficial in their exploration of the psychological state of their patients. Unless these physicians were given additional training during their service, they may not see much point in recognizing diseases for which they think there is no adequate treatment. 2 So, interrelation between chief presenting complains of depressive disorder with level of stigma associated, with reference to patient's socio economic and demographic background is an important issue to identify depression.  7 to assess the most troubling patient-specified symptoms and stigma among the selected patients. In a pilot study (Chowdhury et al, 2001), the interrater reliability of the most troubling patient-specified symptom was good (kappa=.74), and for the section in which stigma items were extracted, interrater agreement was excellent (kappa=.89). The 13 items included in the assessment of stigma, and the internal consistency, as indicated by Cronbach's alpha (.67), was sufficient to justify their use in a linearly combined unweighted scale. The items of the stigma scale had homogeneous variance; each item had a value from 0 to 3 with higher scores indicating more stigma, and the theoretical maximum scale score was 39. 8 Methods 60 subjects; presenting for the first time to the outpatient clinic at the Department of Psychiatry, IPGME&R, Kolkata, West Bengal, were included as per inclusion criteria by purposive sampling. They were screened for any features that meet exclusion criteria listed before. Patients fulfilling any exclusion criteria, those patients were excluded.
The objectives of the study were explained to them and if they agreed, informed consent was taken. Then; a research interview was conducted using the specified tools for this study before any treatment was initiated.
Their age, sex, residence, marital status, family structure, family history of psychiatric illness, educational qualification, were noted using the semi-structured proforma designed for this study, and socio-economic status were determined using Kuppuswamy's Socioeconomic Status Scale-Updated for 2007 (for urban population) and Pareek's Socio-economic Status Scale (for rural population).
All subjects were rated with Hamilton depression rating scale to assess severity of their depression.
Selected portion of EMIC Questionnaire (Distress questionnaire & Stigma scale) Bengali version (Chowdhury et al, 2000) were used to assess the most troubling patientspecified symptoms with reference to four broad categories of symptoms (sadness, pain and other somatic, mental tension and others) and total perceived Stigma (illness experience) with reference to 13 items directly related to stigma, which had been derived previously in pilot study by Chowdhury et al (2000) 8 among the selected subjects.
All collected data were then tabulated and entered in a SPSS-13 (R) spread sheet, analyzed and assessed properly with appropriate use of statistics.

Statistical analysis
The statistical analyses were done using Statistical Package for the Social Sciences, version 13 (SPSS-13). The sociodemographic and clinical variables (both continuous & discrete) were summarized in terms of frequency, percentage, mean & standard deviation as per applicability. To compare difference in terms of mean stigma and HDRS scores across different most prominent presenting complaints (patient specified) of study population; one way ANOVA was done. To measure the relationship among continuous clinical and socio-demographic variables; Pearson's correlation test and for discrete variables; spearman's correlation test were done. The relationship between depression and stigma scores were examined with simple linear regression and computation of Pearson's correlation coefficient. As the mean stigma score of the sample was 16.10; a median split of the data was done to make two groups (patients having stigma score ≥16, considered high and < 16, considered low). To measure the significance of difference among the groups; in terms of various socio-demographic variables, chi square for discrete variables & for continuous variables, t-test was applied.

Ethics
The protocol was submitted to and approved by the Ethics Committee of Institute of Postgraduate Medical Education & Research (IPGME&R), Kolkata. Informed consent was taken from each patient participating the study. Each patient's name was replaced by an abbreviation in the study database to ensure confidentiality.    The relations among the continuous Socio-demographic & Clinical Variables have been shown in this table. Relation between age and total stigma score is insignificant (r=0.14, p=0.285) where as there is a positive correlation exists between HDRS score and total stigma score (r=0.490) which is strongly significant at p<0.001 level.    There were 08 (25.0%) males and 24 (75.0%) female in high stigma group with mean age 35.09±10.42 (SD) years whereas 09 (32.1%) males and 19 (67.8%) females in low stigma group with mean age 37.35±8.87 (SD) years. Thus the two groups were comparable with respect to age (F=3.566; p=0.373) and sex (χ 2 =0.375; p=0.54). There was no significance difference between the groups with respect to marital status (p=0.061) but there was a trend towards significance. The groups were also comparable with respect to religion (p=0.131), education (p=0.375), family structure (p=0.427), residence (0.603), socio-economic status (p=0.131). Within high stigma group there were 23(71.8%) married, 7(21.8%) unmarried, 2(06%) widow among them 27(84.3%) Hindu and 5(15.6%) Muslim, 17(53.1%) were from urban along with and 15(46.8%) from rural background along with 15(46.8%) having joint family structure and 17(53.1%) having nuclear family. Within low stigma group there were 26(92.8%) married, 01(03.0%) unmarried, 01(03.0%) widow among them 19(67.8%) Hindu and 09(32.1%) Muslim, 13(46.4%) were from urban along with and 15(53.5%) from rural background along with 16(57.1%) having joint family structure and 12(42.8%) having nuclear one.

Results
There were statistically significant differences between groups with respect to distress patterns (p<0.001), family history of psychiatric illness (p<0.05) and HDRS scores (p<0.001).

Discussion of methodology
It is an established fact that there is a role of somatization in many parts of the world, where it often accounts for 'common presenting features of depression' 9 and today it is clear that somatic symptoms and complaints are frequent in all populations suffering from depression and in people with different degrees of education. 10 There are many studies focusing importance of somatic symptoms in recognition of depression but no consensus over the instrument to use. Most of the studies used rating scales mostly patient rated (like CES-D, SSI, SRQ etc), [11][12][13] few studies used patient's account of symptoms, symptom checklists and self reported questionnaire specially prepared for, [14][15][16] which may lack psychometric property and may also ignored patient's experiences of distress; which ultimately turn him / her towards help seeking.
Same thing happened in case of measurement of stigma. Derived from many socio-anthropological theories as well as addressing different dimensions of stigma related to mental illness as a whole (like public / personal, felt or self, perceived, stigma associated with treatment and many more) scales were developed with reference of local ethno cultural context and used to measure stigma. 17 few researchers tried to make depression specific stigma scale also. 18 Keeping clinico-epidemiological utility in mind, with reference to cultural perspective, locally adapted Bengali version 7 of the EMIC (internally consistent with Cronbach's alpha of .67, consisting of 13 items and depending upon subjective response rating was done; 0=no, 1=uncertain, 2=possibly, 3=yes, one item (no.2) contains reverse rating); which employed the framework of cultural epidemiology to examine illness-related experience, meaning and behavior, was used to examine pattern of distress (Interrater reliability was good; kappa=.74) and measure stigma (interrater agreement was excellent, kappa=.89) among selected patients in this present study in which an effort was made to find out relation between most distressing symptomatic presentation of major depressive episode; diagnosed clinically as per DSM-IV TR criteria, with stigma along with severity of depression measured by HDR Scale (17 item scale was used in contrast to few studies 19,8 where 24 items was used without any extra benefit).
Regarding selection of study population many studies were population based (though many of them took sample via internet response), 10,14,20 but substantial number of studies were used purposive sampling at outpatient department of a health institute 19,7,12 which was followed in this present study with a more stringent inclusion and exclusion criteria to focus solely on unipolar depression presents at clinical setting excluding comorbid conditions which may confound the purpose of the study.
So, considering all the limitations of the previous studies this present study designed to incorporate both quantitative and qualitative aspect of illness experience including stigma and to relate that experience in recognition of clinical condition (major depression) and its severity; along with its impact over public health system. The impacts of socio-demographic variables over pattern of distress were also explored in a systematic way (using socio-economic status scale, Kuppuswamy's scale for urban people, Pareek's scale for rural people) which was not stressed in other studies of same kind, 8,19 to get a reflection of the socio-cultural influence over presenting style of depressive patients of West Bengal.

Discussion of Results
Socio-demographic and clinical characteristics All 60 participants diagnosed having major depressive episode as per DSM-IV-TR criteria, 30% of them having positive family history of psychiatric illness. As per patient's identification of most troubling symptom; patterns of distress of study population was determined and broadly categorized as Sadness, Pain and other somatic complaints, Tension and others; it was noticed that almost half (48.3%) of the participant of this study complained pain and other somatic problems which is in concurrence with the previous studies conducted at local, national, international levels. 10,12,21 Only a few 20% complaint sadness, 20% tension and 11.7% identified other problems as most troubling. Mean HDRS and Stigma score of the total study population were 20 (SD=23.82) and 16.10 (SD=4.68) respectively. For statistical purpose data was given a median split considering mean and median of total stigma score (median=16) of the study population. 53.3% were found having stigma score 16 or above considered high and 46.7% having less than 16 considered low.
Though western-nonwestern discrimination regarding somatic presentation of depression does not exists today 2 yet controversies exists regarding the explanation of this phenomenon but there is consensus regarding importance of somatizing tendency of depressive patients in recognition of depression at earliest and its enormous impact over the nation's economy. One popular hypothesis is cultural influences the perception of illness and plays an important role in shaping up idioms of depression. For example Kleinman 22 pointed out that in many parts of Chinese society, the experience of depression is physical rather than psychological, many of whom find the diagnosis of depression morally unacceptable and experientially meaningless. Culture influences the experience of symptoms, the idioms used to report them, decisions about treatment, doctor-patient interactions, the likelihood of outcomes such as suicide, and the practices of professionals. But it is also evident that majority of patients who somatize used to reveal psychosocial aspects in response to careful probing. Only a few, < 20% is true somatizer. 23 Supporting Raguram et al, 19 Patel 24 argued about the role of stigma in expressing psychological distress.
Relationship between depression severity and stigma with respect to patterns of distress From table 2 it is evident that patients complaining sadness having highest HDRS and stigma scores (24.08±4.71, 21.25±2.92) and somatic complainer having the lowest one (17.79±1.31, 13.58±3.72) in both cases the differences were highly significant statistically (one way ANOVA; df-3, F=14.54, for HDRS and df-3, F=12.68, for stigma) at p<0.001 level, one possible cause for this observation may be that, mild and moderate depression tends to present somatic complaint. On further analysis to find relationship between depression severity in terms of HDRS score and stigma, it is found that both of them highly related with each other, positive correlation exists between them (r=0.49, p<0.001), simple linear regression was done in search of further evidence of their relationship; and found that stigma score was positively correlated with depression score (R 2 =0.24). This finding was consistent with findings of Raguram and colleagues 19 (r=0.47, R 2 =0.22) and Cheng-Fang Yen and colleagues. 12 So, it can be the explanation why depressed people somatize. According to Raghuram and Weiss 19 through qualitative analysis of patients' narratives, we also demonstrated that patients viewed depressive, but not somatic, symptoms as socially disadvantageous. Somatic symptoms were considered to be less stigmatizing since they resembled illness experiences that most people could expect to have from time to time. 25 It is important to address the issue of stigma related personal and social context with reference to local cultural perspective to improve recognition of depression at earliest; even in milder form as it also causes significant distress along with loss of productivity and to prevent wastage of resources in search of organic cause. It is also relevant from clinical point of view as Angst et al reported that among people with depressive disorders, those who received antidepressant treatment had lower mortality rates than those who did not receive treatment, due in part to the lower suicide rates of those treated and in part to the lower mortality from cardiovascular and other physical disorders. 26 Relationship between socio-demographic variables with patterns of distress There are no statistically significant relation exists between distress patterns and sex (ρ=0.093, P=0.481), marital status (ρ=0.025, P=0.849), religion (ρ=0.054, P=0.684), education (ρ=0.118, P=0.368), family structure (ρ=0.151, P=0.250), residence (ρ=0.076, P=0.562), SES (ρ=0.138, P=0.292), family history of psychiatric illness (ρ=0.175, P=0.182).