CHAPTER TWO

REVIEW OF LITERATURE

2.1 MEANING AND NATURE OF DEPRESSION
Depression, according to World Health Organization’s department of mental health (2012) is a common mental disorder that presents with depressed mood, loss of interest or pleasure, decreased energy, feeling of guilt or low self worth, disturbed sleep or loss of appetite and poor concentration10.

In the text ‘Clinical medicine’ it was reported that the etiology of depressive disorders is multifactorial with a mixture of genetic and environmental factors14. The risk of unipolar depression in first degree relatives of a patient is three times the risk of the non-affected. The existence of unipolar depression in monozygotic twins is between 30% and 60%, the concordance increasing with more recurrent illnesses. Some biochemical changes like mono amine deficiency and dietary tryptophan depletion have also been implicated. Sleep patterns are also contributors as a reduced time between onset of sleep and REM sleep and reduced slow wave sleep occur in depressive illnesses. Families with several sufferers of depressive illnesses share these traits suggesting that sleep patterns may be inherited and predisposed to depression.

Environmental factors such as physical, sexual and emotional abuse or neglect in childhood all predispose adults to depressive illnesses but the effect is non-specific. Social factors contribute to the incidence of Major depressive disorders as depressive illnesses could occur after severe life events or difficulties such as Divorce, unemployment and interpersonal losses. Stress is more likely to trigger depressive illnesses in a person predisposed to lack of social support and/or certain personality traits. Stress in turn triggers various brain changes in both stress hormones (Corticotrophin releasing hormone) and neurotransmitters (e.g. serotonin) which are known to be altered in depressive illnesses. In addition to the above listed etiologies of depression14.

In a study on depression, it was noted that exposure to certain pharmacological agents such as reserpine; beta blockers, cocaine, amphetamine, narcotics and alcohol are associated with higher rates of major depressive disorders8.

The National Alliance for Mental Health discovered that chronic (long term) illnesses are related to increased symptoms of depression. Such chronic illnesses include heart disease, Parkinson disease, multiple sclerosis, stroke, cancer, diabetes and chronic pain syndrome among others15.

It has been suggested that depression should not be dismissed as “normal” reaction to chronic illness but it is common. Facing a chronic illness naturally leads to feelings of uncertainty, grief, sadness, anger or fear. But when these feelings continue and disrupt quality of life and day to day function, depression may be the culprit. Behavioural reactions during chronic illness associated with depression include decreased adherence to treatment, being more likely to smoke and drink, lack of physical activity, poor eating habits, etc. Because of these behaviours the effects of chronic illness and the prospects of recovery may worsen. When symptoms of depression are present alongside symptoms of chronic illnesses, the treatment is similar to the recommended treatment for people with depression. Persons with depression should seek treatment as soon as depressive symptoms appear because early treatment is more likely to be effective15.

Clinical Medicine’s view on the characteristic / features of depressive illness reveals a miserable or irritable mood, impoverishment, slow and monotonous speech, feelings of guilt, self-reproach, unworthiness, impaired learning, insomnia, worry, suicidal thoughts, loss of libido, poor appetite, retardation or agitation, poverty of movement and expression and hallucinations14.

They further classified depressive disorder into bipolar and unipolar affective disorders. Bipolar disorders combine depression and mania. They are classified into three namely; bipolar disorder1, bipolar disorder 2 and bipolar disorder 3. Bipolar disorder 1 is defined as one or more manic or mixed episodes with signs of mania and depression. Bipolar disorder 2 is defined as depressive episode of hypomania (that is shorter lived than mania and is not accompanied by psychotic symptoms). Hypomania is noticeably abnormal but does not result in functional impairment or hospitalization. Bipolar disorder 3 is less well established and describes depressive episodes with hypomania occurring when only taking an anti-depressant.

About 10% of patients who have depressive illnesses are eventually found to have bipolar illnesses. Unipolar disorder patients on the other hand suffer from depressive episodes alone. Under unipolar disorders we have dysthymia, seasonal affective disorder and puerperal affective disorders. Dysthymia is a mild or moderate depressive illness that lasts intermittently for 2years or more and is characterized by tiredness and low mood, lack of pleasure, low self-esteem, and a feeling of discouragement. The mood relapses and remits with several weeks of feeling well, soon followed by longer periods of being unwell14.

Seasonal affective disorder is also another example of unipolar disorder characterized by recurrent episodes of depressive illness occurring during the winter months in the northern hemisphere. Finally we have affective illnesses common in women soon after they have given birth. They include maternity blues(with bouts of emotional lability,irritability, and tearfulness that occurs in about 50% of women 2-3 days postpartum and resolves spontaneously in a few days), postpartum psychosis(occurs within the first two weeks following delivery and patients usually have delusional ideas that the child is deformed, evil or otherwise affected in some way and such false ideas may lead to attempts to kill the child or suicide) and non-psychotic postnatal depressive disorders(occurs during the first postpartum year especially in the first three months)14.

2.2 GLOBAL BURDEN OF DEPRESSION

According to WHO, Depression affects more than 350 million people of all ages, in all communities, and is a significant contributor to the global burden of disease. The world mental health survey conducted in 17 countries found that on average about 1 in 20 people reported having an episode of depression in the previous year. The demand for curbing depression is on the rise globally. A recent World health Assembly called on the WHO and its member states to take action in this direction. Although there are known effective treatments for depression, access to treatment is a problem in most countries, and in some countries, fewer than 10 per cent of those who need it receive such treatment9.

While depression is the leading cause of disability for both males and females, the burden of depression is 50 per cent higher for females than males (WHO, 2008).In fact, depression is the leading cause of disease burden for women in both high-income and low- and middle-income countries (WHO, 2008)9.
Prevalence of depression – One out of 10 people suffer from major depression and almost one out of five persons has suffered from this disorder during his (or her) lifetime (one-year prevalence is 10 per cent and lifetime prevalence 17 per cent) By 2020, depression will be the second leading cause of world disability, and by 2030; it is expected to be the largest contributor to disease burden9.

A study on Depression (a leading contributor to the global burden of disease) observed that while depression was not a significant cause of mortality, it seriously reduced the quality of life for individuals and their families; it was a risk factor for suicide, and often worsened the outcome of other physical health problems16.

Unfortunately, depression is particularly problematic in developing countries, where data on the prevalence and scope of the disease as well as the resources to address it are sorely lacking. Cost-effective interventions are available, but do not often reach those who need them because of a number of overwhelming challenges in low-resource settings—lack of facilities and trained mental health personnel, questions about effective population-based screening, and the general stigma surrounding mental disorders16.

The work on Diabetes and depression (Global perspectives) revealed a 16.2% lifetime prevalence of a major depressive disorder in the U.S. In Europe it was 14%. Another study designed to examine the prevalence of mood disorders in 14 countries in America, Europe, Middle east, Africa and Asia found that the 12 month prevalence of mood disorders was 0.8% in Nigeria, 3.1% in Japan,6.6% in Lebanon, 6.8% in Columbia,6.9% in Netherlands,8.5% in France,9.1% in Ukraine and 9.6% in the United states12.

Studies show that depression is a major cause of morbidity, mortality and disability and is associated with work place absenteeism, diminished or lost work productivity and increased use of health care resources. Finally Major depression is the second leading cause of disability adjusted life years loss in women and the tenth leading cause of disability adjusted life years in men12.

In discussing the Global burden of depression World health organization suggested that while the global burden of depression poses a substantial public health challenge both at the social and economic levels as well as clinical level there are a number of well-defined and evidence based strategies that can effectively address this burden. Many prevention programs implemented across the life span have provided evidence on the reduction of elevated levels of depressive symptoms10. Effective community approaches to prevent depression focus on several actions surrounding the strengthening of protective factors and the reduction of risk factors. Examples of strengthening protective factors include school based programs targeting cognitive, problem solving and social skills of children and adolescents as well as exercise programs for the elderly. Intervention for parents of children with conduct problems aimed at improving parental psychosocial well-being through provision of information and training in behavioral childrearing strategies may reduce parental depressive symptoms with improvement in the children’s outcome10.

2.3 SOCIAL STIGMA ASSOCIATED WITH DEPRESSION

According to the American Psychiatric Association, there are varying degrees and types of depression ranging from short lived bouts of feeling sad to a full diagnosis of major depression. Depression is still surrounded by social stigma. Often, people hide their depression from others and then become seriously ill. The physical illness can be associated with actual physical symptoms caused by the depression17.

Those living with depression may try to find ways to escape the feeling of sadness and anxiety and become tempted to experiment with non-prescription drugs, which can lead to general physical neglect and addiction issues. Depression in its darkest form is associated with suicidal behaviors. This makes depression a potentially life-threatening illness and it is the time when the individual most needs support and guidance. Unfortunately this support is rarely given17.

Historically what we now term as mental illness has been associated with the terms ‘madness,’ ‘lunacy,’ insanity, all of these words conjure up imagery of someone who has lost control. A historical fact is that there have always been two sides to the social acceptance of ‘mad’ people.

The first possibility that the ‘mad’ will be celebrated as visionaries or artists. The second possibility is that the ‘mad’ will be socially alienated, labeled, locked away or even thought to be possessed by demons .Unfortunately throughout history more ‘mad’ individuals are stigmatized by society rather than being accepted and celebrated. They become overshadowed by the label17.

A study was carried out on the predictors of depression stigma. The aim of the study was to investigate and compare the predictors of personal and perceived stigma associated with depression. Three samples were surveyed to investigate the predictors: a national sample of 1,001 Australian adults; a local community sample of 5,572 residents of the Australian Capital Territory and Queanbeyan aged 18 to 50 years; and a psychologically distressed subset (n = 487) of the latter sample.

In the analysis of the results gotten sample 1 revealed that personal stigma was significantly higher for those who were older, and men. Personal stigma was also higher for people with lower levels of exposure to depression (those who had not previously experienced depression or who reported no depression among members of the family or who had not provided treatment or services to people with depression), in those who failed to recognize the person in the vignette as depressed, and in those who were unaware of Australia’s national depression initiative. Remoteness of residence did not affect personal stigma levels. Being born overseas was associated with higher personal stigma independently of other demographic variables, but this effect disappeared when non-demographic predictors were included in the model18.

The percentage of variance explained by the model for perceived stigma was very small (1.6% compared to 22.9% for personal stigma) and the pattern of findings for perceived stigma consistently differed from that for personal stigma. In contrast to the results for personal stigma, perceived stigma was lower (rather than higher) for older people and experience with a family member with depression predicted higher (rather than lower) perceived stigma. Moreover, in contrast to personal stigma, the demographic variables of sex, educational level and country of birth did not predict level of stigma nor did knowledge of the disorder, awareness of Australia’s national depression initiative or being a service provider. The only similarity between the findings for the two types of stigma was that a self-disclosed history of depression predicted both lower perceived stigma and lower personal stigma and remoteness of residence predicted neither perceived stigma nor personal stigma18.

The pattern of the results in sample 2 was broadly consistent with that for the national dataset, with personal stigma higher in men, those with less education and in those with less exposure to depression. Age in years failed to predict level of personal stigma, but there were no participants older than 50 years in Sample 2. In contrast with personal stigma, females (rather than males) showed higher levels of perceived stigma and those with greatest self-reported contact with depression showed the greatest perceived stigma. Higher perceived stigma was associated with older age. As for Personal Stigma, lower educational levels and higher current psychological distress were associated with higher perceived stigma18.

In the third sample, personal stigma was also higher among those with less education, but this effect disappeared when psychological distress and depression literacy were added to the model. There was no association between age and personal stigma or perceived stigma. Nor was there an association between perceived stigma and depression literacy or gender. However, higher perceived stigma was associated with lower education and greater psychological distress18.

The findings from this study therefore suggested that in addition to delivering broad-based programs to reduce personal stigma, there may be value in targeting and tailoring programs to reduce personal stigma among men, older people, and those with lower educational levels and those born overseas. Consideration should also be given to developing destigmatisation programs for people with symptoms suggestive of psychological distress and to improving depression literacy. The effects of sociodemographic and other factors on perceived stigma were very small. However, perceived stigma is very high both in people with depression and the general public and may impact on help seeking. This suggests the appropriateness of programs at all levels (national and clinically targeted) designed to reduce perceived stigma, including those publicizing the actual levels of personal stigma18

2.4 CARE AND TREATMENT OF PEOPLE WITH DEPRESSION
It was observed that a lot of people are unable to identify or recognize depression when their loved ones experience it13.In developing countries where depression is eventually recognized by the families of the depressed persons they shy away from consulting psychiatrist for fear of the victims being stigmatized or labeled insane persons. Instead, they patronize traditional healers and religious priests for ‘deliverance’. People patronize them because the healers and the priests are of close proximity, they are easily accessible and the costs involved in the treatment they give are affordable.

The traditional Healers’ skepticism for conventional orthodox medical treatment and their unrefined practices raise concerns about the victims’ safety and human rights. Also the societal poor understanding and negative perception of depression / mental illness as ‘madness’ make the victims get chained and beaten up unnecessarily when they are under the grip of depression. A lot of depressed persons are perceived as abnormal persons, treated like outcasts and abandoned by their families and friends. What people who do these therefore need to understand is that victims of depression are victims of circumstance and such people need love, care and support to enable them overcome the ordeal13.

In the work done on the treatment and management of depression in Nigeria it was revealed that depression is a broad and heterogeneous diagnosis. Central to its depressed mood or loss of pleasure in most activities severity of the disorder is determined by the number and severity of symptoms as well as the degree of functional impairment. A formal diagnosis using the ICD-10 classification system requires at least four out of ten depressive symptoms, whereas the DSM-1V system requires at least five out of nine for a diagnosis of major depression. Symptoms should be present for at least 2weeks and each symptom should be present at sufficient severity for most of everyday. Both diagnostic systems require at least one (DSM-1V) or two (ICD-10) key symptoms (low mood, loss of interest and pleasure or loss of energy to be present19.

2.5 STUDIES ON THE KNOWLEDGE OF DEPRESSION IN DEVELOPED COUNTRIES

A study was done in Australia to determine the degree of recognition and understanding of depression and its treatment. It was a cross sectional survey of a representative community sample of 900 randomly selected respondents. A telephone survey of these respondents was conducted across four states in Australia (New South Wales, Victoria, Queensland, and South Australia). The 900 respondents had a mean age of 44.5years with ages ranging from 18-94years20

The respondents were asked about major mental health problems for Australians and depression was spontaneously identified by 39% of them followed by anxiety /stress/pressure by 18%. Schizophrenia was identified by 11% of respondents while Alzheimer’s disease and alcohol/substance misuse was identified by 6% and 5% of the respondents respectively.14% indicated they did not know of any major mental health problem in Australia20.

The debilitating nature of depression relative to other physical conditions was also recognized. When compared with Diabetes, arthritis and asthma, depression was perceived to have the greatest impact on quality of life for more than half the sample20.

In the second part of the survey, respondents were asked questions on their knowledge of depression. Question about the main signs/symptoms of depression was asked and how to tell the difference between normal sadness and depression. Importantly 50% of respondents could differentiate depression from normal sadness indicating depression to be more intense, constant and long lasting20.
With respect to common risk factors 97% agreed on unemployment as a major risk factor, 95% also identified serious medical condition as a cause, and 72% recognized the birth of a child as being associated with depression. Having a job with lots of responsibility was rated as a risk factor by 67% of respondents20.

When asked about the likely effects of various treatment approaches, respondents believed that both self-help (e.g. exercise, yoga) and specific psychological strategies were highly likely to be helpful. Among the pharmacotherapies, specific antidepressants rather than sleeping tablets or sedatives were likely to be helpful. However a quarter of respondents perceived antidepressants to be harmful20.
In another study It was proposed that community facilitators such as pharmacists, policemen, teachers and clergy may be an important community resource for patients with depression in addition to mental health professionals. However they are ill prepared for such a role and little is known about their attitudes towards depression which may affect practice21.

They therefore carried out a study to investigate community facilitator’s knowledge of depression and compared their knowledge to those of (mental) health professionals and nurses’. Knowledge of depression was assessed in participants from nine countries of the European alliance against depression (EAAD). A total of 2,670 participants in all were used. The EAAD questionnaire included knowledge of depressive symptoms, perceived causes, and preferred treatment options. Data were collected from the nine EAAD partner countries namely Belgium, Estonia, France, Germany, Hungary, Ireland, Italy, Scotland and Slovenia. The proportion of male and female respondents were 15.7% and 84.3% respectively21.

When question was asked whether depression was a real disease, an average of 77% in the three groups agreed. A high percentage of each group of respondents were of the opinion that depression can be treated. When asked whether anti-depressant was effective in the treatment of depression, about half of the community facilitators and nurses agreed while a higher percentage of (mental) Health professionals agreed.

In the response given to the question whether anti-depressant was addictive, 53.8% of community facilitators strongly agreed, 67.8% of nurses strongly agreed and only 24.8% of mental health professionals agreed.

A list of possible causes of depression was presented to the respondents to determine their awareness of the items on the list as capable of causing depression. The following were the researchers’ findings: On asking whether depression could be caused by wrong lifestyle, less than half of respondents from the three groups answered in the affirmative. The question whether depression could be caused when ones has problems with other people was reported to have attracted very low positive answer from all the three groups of respondents: 8.5% of community facilitators strongly agreed, 6.1% of nurses strongly agreed and 9.8% of (mental) health professionals strongly agreed.

When asked if disorder of brain metabolism could cause depression, the percentage of respondents who strongly agreed in each group was relatively high. 52.5% of community facilitators strongly agreed, 67.4% of nurses strongly agreed and 71.8% of (mental) health professionals strongly agreed.
More than 80% of all the three groups of respondents strongly agreed that life events could cause depression. The question on heredity as possible cause of depression elicited average percentage of affirmative response in all the three groups; 43.6% of community facilitators, 56.5% of nurses and 65.1% of (mental) health professionals agreed.

The criterion of environmental poison being cause of depression was hardly supported because the percentage of respondents who agreed in each group was abysmally low. 20.4% of community facilitators for example agreed, 19.2% of nurses agreed and 19.3% of (mental) health professionals agreed.

A list of treatment options for depression was presented to the respondents: community facilitators, nurses and (mental) health professionals to know which ones they agreed with and which they did not agree with. On the list among others were such options as ‘contact a doctor’, take anti-depressant (AD) and ‘contact a non-medical (alternative) practitioner’21.

The response to the option ‘contact a doctor’ was in the following order: 69.5% of community facilitators agreed, 79.5% of nurses agreed and 81.3% of (mental) health professionals agreed. A high percentage of the respondents in each group also agreed with the option ‘take AD’: 56.6% of community facilitators agreed, 47.9% of nurses agreed and 83.7% of (mental) health professionals agreed.
In each group however, less than 50% of the respondents agreed with the option that a non-medical (alternative) practitioner should be contacted. A list of depression symptoms was presented to the respondents again to know their responses to such symptoms as hallucinations, feelings of guilt, loss of pleasure, physical complaints and compulsive grooming21.

More than 80% of respondents in each group agreed that feeling of guilt is a symptom of depression. Loss of pleasure appears to be the most supported symptom of depression as at least 90% of the respondents in each group strongly agreed with it21.

A study was carried out to learn more on the General practitioners’ knowledge of depression in Turkey. The survey was conducted in the year 2002 using face-to-face interviews in offices of 300 general practitioners. Data were derived from the questionnaire developed for the survey22.

From the results, when depression was given as a term, 95.3% of the physicians considered it as disease, while 4.3% considered it a mental disease, 99% felt it was treatable disease (97.3%with drug therapy, 93.6% with psychotherapy) and 90.7% saw depression as a totally curable disease. According to the responses given to the questions in which the depression was given as a case, 98.7% of the physicians thought that the case has a psychiatric disorder while 6.3% thought it was a physical disease, 92.3% advised to consult a physician, 74.3% to a primary care unit physician and 24.7% to a psychiatrist. It was found that 80% of the physicians think that depression is the state of being deeply sad, 47.3% saw depression as a psychologically weak state while 39.7% do not consider it a disease but as a state that everybody may have from time to time. When questions were asked about the causes of depression, 94.7% believed it could be caused by social problems, 8.7% thought that it is contagious and 7.4% considered it congenital. Some 25.3% thought that there are severe side effects of the drugs, 20.5% believed the drugs could be addictive, 12.7% thought that mystic or religious people may be of help,66.3% thought that it cannot be treated without solving the social problems, 89.3% declared that change of environment may contribute to treatment.32.3% believed that personality weakness could precipitate depression22.

2.6 STUDIES ON KNOWLEDGE OF DEPRESSION IN DEVELOPING COUNTRIES

A study was carried out in South Western Ethiopia among nursing staff to determine their knowledge of depression. A total of 135 Nurses were included in the study.The results gotten revealed that about 89% of the respondents were knowledgeable about mental health problems, 79 and 23 percent of whom got the information from schools and health professionals respectively. Respondents were asked about perceived symptoms of depression and the following answers were given; 15% agreed on suicidal attempts, 17% thought nakedness could present as a symptom, 25% and 40% agreed on restlessness and aggression respectively.30% of respondents believed talking alone was an important feature.35% agreed on talkativeness and 42% thought sleep disturbance was one of the prominent symptoms of depression. A considerably large 78% of respondents agreed on self neglect as a symptom of depression23.

Questions on the probable causes of depression were also asked.5% of respondents believed depression could be as a result of God’s will.15% of respondents agreed evil spirits and heredity could play a role in the precipitation of depression. 30% felt it could be as a result of other non-mental illnesses. Poverty was also identified as a cause by 40% of respondents. About 75% agreed on biochemical disturbance as the most probable cause of depression22.

In the study of the ‘Knowledge and attitude of General Practitioners towards depression’ it was observed that in a variety of primary care settings in Tanzania depression is rarely recorded as a reason for consultation. A study was therefore carried out to ascertain the current status of the knowledge, attitude and practice pertaining to depression among primary health care workers. Fourteen primary health care workers in four primary health clinics were asked to complete the Depression attitude questionnaire. All the primary health care workers were between the ages of 40 years and 55 years (except one whose age was 27 years), half were males and half were females24.

From the results, two thirds did not feel they had difficulties in differentiating between unhappiness and a clinical depressive disorder that requires treatment, and, the majority of primary care workers felt that it is possible to distinguish two main groups of depression, one psychological in origin and the other caused by biological mechanisms. The vast majority of primary care workers also acknowledged the role of life events in the development of depression.; however, only 29% believed that depressed patients are more likely to have experienced deprivation early in life. The majority of primary care workers believed that biochemical abnormality was the basis of severe depression24.

Concerning the treatment of depression, half of the sample disagreed with the statement that depressive disorders improve without medication. The vast majority of primary care workers believed that psychotherapy would be more beneficial than antidepressants for most depressed patients. Only 40% of primary health care workers believed that if depressed patients need antidepressants, they would be better off with psychiatrists than community health workers; but 70% primary care workers agreed with the statement that psychotherapy for depressed patients should be left to specialists. Over two-thirds of primary care workers disagreed with the statement that depression reflects a characteristic response which is not amenable to change. Almost four-fifths of primary care workers felt that antidepressants usually produce a satisfactory result in the treatment of depressed patients in general practice24.

In Nigeria a study was done to determine the knowledge of depression among general practitioners in Benin. A cross sectional survey of 72 general practitioners (GPs) was undertaken and a depression attitude questionnaire was used to assess their knowledge of depression. 68.1% of respondents were males and 31.9% were females. Their ages ranged from 28 to 68 years with a mean age of 38.425.

According to the results gotten, the majority (61.1%) of GPs agreed that it was possible to distinguish between the psychological and biochemical origin of depression. About 56.9% endorsed the statement that a biochemical abnormality is the underlying cause of depression.

Another study was carried out in Nigeria by Oye Guruje et al to determine the knowledge of depression among a representative community sample in Nigeria. The survey was conducted in three Yoruba-speaking states in south-western Nigeria (Ogun, Oyo and Osun) between March and August 2002. A total of 2040 individuals participated about 47.3% were males and 52.7% were females. Participants were aged 18 years and above26.

When questions were asked about the possible causes of depression, the following results were gotten; 80.8% agreed to drug/alcohol use, 30.2% endorsed evil spirits as a cause, 29.7% and 29.2% respectively believe that traumatic event or shock were precipitating factors for depression. Genetic inheritance had 26.5% while 14.7% agreed on physical abuse as a cause. 9.3% and 9.2% of respondents agreed on God’s punishment and brain disease. A small percentage of 6.2% believed poverty could be a cause of depression26.

2.7 STUDIES ON ATTITUDE TO DEPRESSION IN DEVELOPED COUNTRIES

In Ireland, a study was carried out to obtain a comprehensive view of attitudes to mental health among the Irish adult population. A total of 1000 participants were involved. They were aged 18 and above. A research questionnaire was used to obtain information from the respondents27.
The series of questions started with the asking of respondents if they believe anyone can experience mental health problems (depression) 58% of participants answered yes. The next question asked was if people with mental health problems should have the same rights as anyone else. 52% agreed to this. About 62% of participants would not want people knowing if they had mental health problems. When asked if majority of people with mental health problems recover, 48% agreed.

Questions on whether people with mental health should be allowed to do important jobs were asked and less than half of the respondents agreed. Their views on whether “people are generally caring and sympathetic to people with mental health problems” were sort and 52% agreed to the statement. The next question was asked thus “Should the public be better protected from people with mental health problems” 34% agreed .About 62% of the respondents were afraid of experiencing mental health problems in future27.

Half of respondents were of the opinion that people with mental health problems are dangerous. About 48% of respondents thought there would be no problem talking with someone mentally ill.
The final question was whether people with mental health problems are largely to blame for their own circumstances. 54% thought the statement was true.

A study was done in Australia to determine the attitude to seeking treatment for depression. It was a cross sectional survey of a representative community sample of 900 randomly selected respondents. A telephone survey of these respondents was conducted across four states in Australia (New South Wales, Victoria, Queensland, and South Australia). The 900 respondents had a mean age of 44.5years with ages ranging from 18-94years20.

When the respondents were asked who they would most likely turn to if they thought they might be suffering from depression, they rated their family first (45%,), then General practitioners (28%,) and then friends (15%,). This stated preference varied with age: older people were more likely to see their General practitioner (GP) as the most important resource. However, given that most depressive disorders have their onset before 35 years of age; it is interesting that only 12% of 18–24-year-olds and 19% of 25–34-year-olds rated their GP as their first point of contact. Consistent with the general pattern of GP consultations in Australia, more women (34%) reported that they were likely to seek initial assistance from a GP than men (21) 20.

Of the respondents who identified family and friends as the people they would most likely turn to, when specifically asked “who would be your first point of (professional) contact?”, 71% of respondents identified GPs. Smaller percentages of people reported that they would see a counsellor (9%,), clinical psychologist (5%,), priest/clergy (3%) or specialist psychiatrist (2%)20.

When asked if you were depressed, what would be your first choice of treatment?” respondents indicated a preference for non-pharmacological treatments. Counseling and support from others were the overall treatments of choice, with women in particular identifying counseling. Men were significantly more likely to go out and socialize, go to the pub/have a drink or smoke pot20.

A study was done in Urban Turkey with the aim to determine the public’s attitude towards patients with depression and the influence of perception and casual attributions on social distance towards individuals suffering from depression. There were seven hundred and seven subjects who completed the public survey form which consisted of questions rating attitudes towards depression. 51.5%of participants were males and 48.5% were females. Ages ranged from 18-55years28.

About 22.8% of participants were of the opinion that patients with depression should not be free in the community. On the subject of getting married to a person with depression 27.9% had no problem with it while 64.6% objected and 7.5% had no idea. 68% of respondents believed having a neighbour with depression would irritate them while 27.6% felt they could not cope with having a depressed neighbour and 4.4% had no idea28.

When asked if participants would rent their house to a person with depression 47.1% agreed, 43% disagreed and 9.9% had no idea. 43.3% of respondents felt people with depression are aggressive, 44.8% did not think so and 11.9% had no idea. 77.1% of subjects felt people with depression could make correct decisions about their lives, 18.1% disagreed and 4.8% had no idea28.

2.8 STUDIES ON ATTITUDE TO DEPRESSION IN DEVELOPING COUNTRIES

A research study was carried out in Southern Ghana to determine the attitude of the urban population to depression. A convenience sample of 403 participants from urban regions in Accra, Cape Coast and Pantang filled the Community Attitudes towards the Mentally Ill (CAMI) questionnaire. 210 of the participants were males and 193 were females29.

Results gotten showed that a majority of participants (57.1%) rejected the view that mental illness is an illness like any other , rather it was seen as a consequence of lack of self-discipline and will power by 61.2% of participants. Although virtually anyone may become ill (60.9%), it was generally believed by 79.7% of respondents that it is easy to tell persons with mental illness from ‘normal’ people29.
Regarding the personal distance to persons with mental illness, only a minority (22.9%) endorsed the statement that it is best to avoid persons with mental illness. This positive attitude extended to potential marriage with only 27.6% agreeing that it would be foolish for a woman to marry a man who has suffered from mental illness (57.4% rejected this view). Although 54.6% assented to the statement that no one has the right to exclude the mentally ill from their neighbourhood, 44.4% believed that the mentally ill should be isolated from the community and 39.7% would not want to live next door to someone who has been mentally ill. 50.7–54.8% thought that the risks of mental patients living within residential neighbourhoods are too great. However, locating mental health services in residential areas was not regarded as dangerous by 76.9–80.0% of the respondents29.

In general, the participants felt that mentally ill persons deserve sympathy (72.4%) and should not be denied their individual rights (58.3%) and have for too long been the subject of ridicule (50.4%). The society ought to adopt a more tolerant attitude (66.8% agreed) and although a majority (56.3%) judged that the mentally ill are a burden on society , the responsibility to provide the best possible care for the mentally ill was widely acknowledged by 80.3%. Spending tax money for that purpose was endorsed by 63.3% if the item was positively phrased, but only by 23.3% in its inverted form29.

A study was carried out in Tanzania to ascertain the current status of the attitude and practice pertaining to depression among primary health care workers. Fourteen primary health care workers in four primary health clinics were asked to complete the Depression attitude questionnaire. All the primary health care workers were between the ages of 40 years and 55 years (except one whose age was 27 years), half were males and half were females24.

From the results gotten, almost two-thirds of the sample believed that becoming depressed is a way that people with poor stamina deal with life difficulties, but almost two thirds disagreed with the statement that becoming depressed is part of growing old. The vast majority of primary care workers felt comfortable dealing with depressed patients and felt that they could be a useful person to support depressed patients. The majority of primary care workers felt that it was rewarding to work with depressed patients, but found working with depressed patients “heavy going”. Two-thirds of primary care workers disagreed with the statement that there is little to be offered to those depressed patients who do not respond to treatment from them24.

A study was carried out by to determine the attitude of the general public to mental disorders (depression). A total of 100 subjects were selected conveniently of which 33% were males and 67% were females. Most of them in the age group were above 30 years. A cross sectional survey was conducted in which a questionnaire was designed to assess the attitude of the public to mental disorders.82% of the respondents admitted they do not visit a psychiatrist when they have an emotional problem, 18% confirmed visiting psychiatrists when faced with emotional problems. On the issue of visiting a traditional healer when faced with an emotional problem, 35% agreed while 65% disagreed. About 60% of participants are afraid of staying next door to someone with mental illness while 40% of them have no problems with living close to mentally ill persons.55% have the believe that marriage can treat mental illness while 45% disagreed. 25% of participants cannot maintain friendships with people faced with mental illness while 75% are of are of the opinion that they can successfully maintain friendships with the mentally ill. Finally they were asked if they would be ashamed to mention someone in their family who has mental illness, 55% answered yes and 45% answered no30.

A study was carried out to ascertain the current status of the attitude and practice pertaining to depression among primary health care workers in Nigeria. Fourteen primary health care workers in four primary health clinics were asked to complete the Depression Attitude Questionnaire. All the primary health care workers were between the ages of 40 years and 55 years (except one whose age was 27 years), half were males and half were females26.

The results were as follows; 82.7% of respondents admitted they would be afraid to have a conversation with a mentally ill (depressed) patient. The statement that they would be upset/disturbed about working on the same job with a depressed person was endorsed by 78.1%, the participants who felt that they could not maintain a friendship with a depressed patient were 16.9% and those who would be unwilling to share a room with the mentally ill were 81.2%. On the issue of being ashamed if people in their family were diagnosed with mental illness 82.9% of participants agreed to the statement. Only 3.4% of respondents could marry someone with mental illness26.