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ORIGINAL ARTICLE
Ahead of print publication  

Screening for depression among Nigerian dental patients using patient health questionnaire-19


1 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, College of Medical Sciences, University of Benin, Benin City, Edo State, Nigeria
2 Department of Dentistry, Stella Obasanjo Hospital, Benin City, Edo State, Nigeria
3 Department of Dentistry, Stella Obasanjo Hospital; Department of Periodontics, Faculty of Dentistry, College of Medical Sciences, University of Benin, Benin City, Edo State, Nigeria

Date of Submission29-Apr-2020
Date of Decision24-Jul-2020
Date of Acceptance13-Aug-2020
Date of Web Publication04-Nov-2020

Correspondence Address:
Ekaniyere Benlance Edetanlen,
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, College of Medical Sciences, University of Benin, Benin City, Edo State
Nigeria
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjos.SJOralSci_32_20

  Abstract 


Objective: The objective of this study is to determine the prevalence of depression among dental outpatients in an secondary health facility in Benin City using the Patient Health Questionnaire-19 (PHQ-19).
Materials and Methods: This cross-sectional study was conducted among patients attending the dental outpatient clinic of Stella Obasanjo Hospital between January and December 2018. Consenting adult patients were included while nonconsenting patient and those with chronic medical conditions were excluded. Data collection was through the use of questionnaires and clinical examination. The depression screening tool was PHQ-9. Informed consent was obtained from the participants. Data analysis was done using IBM SPSS version 22.0. Test for association was done using the Chi-square and statistical significance was set at P < 0.05.
Results: About one-quarter (28.6%) had depression of the mild severity. Depression was highest among the 31–40 years, females, those with primary education and those that earn less the 30,000 naira monthly and nonindigenous participants. Participants with mild depression presented more with acute apical periodontitis, dental caries, and periodontal disease than those without depression.
Conclusion: Data from this study on screening for depression among patients attending a secondary facility revealed the low prevalence of depression which was mild in severity. Further studies on patients with symptomatic chronic dental condition are recommended.

Keywords: Acute apical periodontitis, dental patients, depression



How to cite this URL:
Edetanlen EB, Ogbikaya AJ, Azodo CC. Screening for depression among Nigerian dental patients using patient health questionnaire-19. Saudi J Oral Sci [Epub ahead of print] [cited 2020 Nov 25]. Available from: https://www.saudijos.org/preprintarticle.asp?id=299966




  Introduction Top


Depression, which is characterized by sadness, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, tiredness, and poor concentration, is a highly prevalent debilitating mental disorder (MD) worldwide.[1] It affects all persons irrespective of age, gender, race, culture, background, and dwelling place.[2] Globally, an estimated 300 million people are affected by depression with more female affection than male and an increase of >18% (18%) between 2005 and 2015.[3] Depression can be long-lasting or recurrent, affects families and communities and is associated with daily life coping impairment, substantial work impairment, lost work days, and reduced productivity. It has been quoted by the 2010 Global Burden of Disease Study as the second leading cause of years lived with disability (YLD), constituting 8.2% of global YLDs, and the leading cause of disability adjusted life years with a percentage of 2.5%.[3]

Depression is a common but Grave disease which cannot be ignored because it is a substantial contributor to suicide. It is distressful and disabling yet many affected individuals never look for treatment mainly due to stigma. Depression can be reliably diagnosed and treated in primary care with medications, psychotherapies, and other methods such as maintenance or reactivation of social networks and social activities is important.[4] Dental health professionals, may be the first providers in a health system to identify depression.

Dental health-care settings had been cited as a unique venue for the screening of chronic medical conditions which may include hypertension and diabetes mellitus. Screening for depression in dental setting may help chart early course of treatment for affected individuals and also help improve their oral health indices and outcomes. It has been stated that approximately 45% of individuals who committed suicide visited a primary care provider in the month preceding their death.[5] Dentist as a primary care provider may detect this condition, facilitate early referral and treatment with favorable outcome, and ultimately reduce the suicide rate among depressed persons.

Xerostomia, impaired immune function and increased risk of oral infections in undiagnosed depression culminate to poor oral health status and unfavorable oral health outcomes.[6] Reduced energy and motivation associated with depression can affect oral health by neglecting oral hygiene procedures, which leads to an increased risk oral disease. Cariogenic nutrition, avoidance of necessary dental care, and antidepressant-induced xerostomia worsens the oral health indices of depressed persons.[7] McFarland and Inglehart[8] and[9] reported poorer oral hygiene, more carious teeth with fewer restored teeth, declined salivary quantity, more chewing problems, higher speaking difficulties, and worse self-reported oral health status among depressed patients. Depression also has the potential to intensify perceived pain and reduce an individual's capacity to tolerate pain.[9]

Patient Health Questionnaire-9 (PHQ-9) is a depression screening tool with a sensitivity of 88% and a specificity of 88%. It comprises nine questions based on the Diagnostic and Statistical Manual of MDs (DSM-IV) diagnostic criteria. The PHQ-9 was originally designed to improve the detection of depression in primary care and nonpsychiatric settings.[10]

It is brief, has useful diagnostic properties and serve as a valid tool in assessing severity and uniquely serve as a way to track patients' response to treatment.[11] The PHQ-9 is a self-administered scale that was drawn from the Primary Care Evaluation of MDs, and it is based on the DSM-IV5 (American Psychiatric Association, 2000) criteria for major depressive disorder. The burden of depression being on the rise globally and World Health Assembly resolution passed in May 2013 calling for a comprehensive, coordinated response to MDs at the country level.[10] The objective of this study was to determine the prevalence of depression among dental outpatients in a Secondary health facility in Benin City.


  Materials and Methods Top


This cross-sectional study was conducted among patients attending the dental outpatient clinic of Stella Obasanjo Hospital between January and December 2018. Consenting adult patients were included while nonconsenting patients and those with chronic medical conditions were excluded. Data collection was through the use of pretested and prevalidated[12] questionnaires and clinical examination. The depression screening tool was PHQ-9 which is a nine-question depression screening tool. The PHQ-9 items screen for the presence of the following symptoms: anhedonia, depressed mood, trouble sleeping, feeling tired, change in appetite, guilt or worthlessness, trouble concentrating, feeling slowed down or restless, and suicidal thoughts. Each symptom was rated from 0 to 3 based on frequency over the last 2 weeks (0 = not at all, 1 = several days, 2 = more than half the days, and 3 = nearly every day). The minimum score is 0 and maximum score is 27. A score of 0-4 indicates the absence of depression while 5–9 indicate mild depressive symptoms, 10–14 moderate, 15–19 moderately severe, and ≥20 severe depression. Informed consent was obtained from the participants. Data analysis was done using IBM SPSS version 22.0. IBM Corp., Armonk, NY, USA. Test for association was done using the Chi-square and Fisher's exact statistics where applicable and statistical significance was set at P < 0.05.


  Results Top


About one-third (30.5%) of the participants were aged 21–30 years and two-thirds (66.7%) were females. About half (54.3%) of the participants have attained tertiary level of education, and about one-third (38.1%) earn 30–100 thousand naira [Table 1].
Table 1: Demographic characteristics among the participants

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About one-quarter (28.6%) had depression of the mild severity [Figure 1]. More than half (57.1%) of the participants had acute apical periodontitis and about one-tenth (10.5%) of the participants had dental caries [Table 2]. Depression was the highest among the 31–40 years, females, those with primary education and those that earn less the 30,000 naira monthly [Table 3]. Participants with mild depression presented more with acute apical periodontitis, dental caries, and periodontal disease than those without depression [Table 4].
Figure 1: Prevalence of depression among the participants

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Table 2: Dental conditions among the participants

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Table 3: Association between demographic characteristics and depression among the participants

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Table 4: Association between depression and dental conditions among the participants

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  Discussion Top


In this study, 28.6% of the participants reported depression of mild severity. Comparison of the prevalence of depression obtained in this study with the prevalence of depression assessed with PHQ-9 in the general population in Nigeria was not possible because such data did not exist in the literature. However, the prevalence of depression in this study was lower than 58.2% reported among students of a Nigerian University assessed using same tool, PHQ-9.[13] The low prevalence of mild depression among the dental patients may be due to the fact that the individuals with chronic medical conditions were excluded,[14],[15] and none of the respondents had any chronic debilitating dental conditions. The low prevalence of depression in this study may be due to the fact that this study was in an urban setting because depression has been reported to be more in rural than urban setting.[16],[17] Although the prevalence of depression in this study was low and severity only mild, the rapidly changing family and societal ecology favorable to the emergence of depression in Nigerian environment with the rising prevalence of socioeconomic deprivation remains a course for worry. Poverty has been documented to constitute a fertile environment for the genesis of depression, especially in those who are predisposed to depression.[15],[18] This reflected why participants with lower level of education and income earning power reported more depression. This is in tandem with adversity, stress, and reduced capacity to cope related to low income increase the risk of development of mental illness, particularly depression in concert with social causation rather social selection theory link between mental illness and income.[19] Unfavorable social conditions reflected in low levels of schooling and income, making the individual more susceptible to mental health problems such as depression. The close relationship between education and health is a concern, as it has been observed that educationally disadvantaged people are not particularly concerned with healthy living habits.

It has been reported individuals above 45 years are more likely to suffer from depression.[15],[20] However, in this study, depression was higher in participants aged 31–40 years which fall within the age of the majority of the bread winner who are burdened with challenges of supporting and ensuring success of their dependents in midst of unpredictable governmental policies and failure-laden uncertainties.

Females reported significantly more depression than male which may be due to the fact that women exhibit greater tendency to internalize stressful events, have different rights and status than males, and suffer various types of violence, resulting in a higher risk of depression. The higher burden of depression in females in this study could also be due socioenvironmental provoking experiences as females in Nigeria occupy many roles within the family, in the community, and at work. They carry the burden of domestic and household chores in addition to other work/social engagements and the married ones have additional burden of raising and caring for the children.[21] The frequent presence of factors such as low income and low level of schooling in females may also be the contributory explanation for the higher depression.

The nonindigenous people reported more depression than the indigenous people. This is supported by Emmanuel[22] report in Nigeria, and also Shao et al.[23] and Dunlop et al.[24] reports on depression in the United States of America. The differences in environment and resources are likely to contribute to the variations in depression as the ability to meet basic needs is more challenging to the nonindigenous people.

Participants with depression are more likely to have attended the dental clinic with acute apical periodontitis and dental caries. Although not assessed in this study, lower tooth brushing frequency and higher cariogenic nutrition, which are certified a risk factor dental caries, have been reported among depressed individuals.[25] Park et al.[26] reported more frequent incidents of toothache among patients with depression.


  Conclusion Top


Data from this study on screening for depression among patients attending a secondary facility revealed the low prevalence of depression which was mild in severity. Further studies on patients with symptomatic chronic dental condition are recommended.

Acknowledgment

We thank our colleagues and other support staff in the department for allowing us to recruit their patients and for their support and co-operation, respectively.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Depression and Other Common Mental Disorders: Global Health Estimates 2017; WHO/MSD/MER/2017.2. Available from: https://creativecommons.org/licenses/by-ny-sa/3.0/igo. [Last accessed on 2020 Mar 13].  Back to cited text no. 1
    
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Kim YS, Kim HN, Lee JH, Kim SY, Jun EJ, Kim JB. Association of stress, depression, and suicidal ideation with subjective oral health status and oral health functions in Korean adults aged 35 years or more. BMC Oral Health 2017;17:101.  Back to cited text no. 9
    
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Probst JC, Laditka SB, Moore CG, Harun N, Powell MP, Baxley EG. Rural-urban differences in depression prevalence: implications for family medicine. Fam Med 2006;38:653-60.  Back to cited text no. 16
    
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Shittu RO, Odeigah LO, Issa BA, Olarirewaju GT, Mahmoud AO, Sanni MA. Association between depression and social demographic factors in a Nigerian family practice setting. Open J Depress 2014;3:18-23.  Back to cited text no. 18
    
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22.
Emmanuel LR. Prevalence and correlates of depression, anxiety and academic stress among science students in Oduduwa University, Ile- Ife, Nigeria. Texila Int J Pub Health 2016;4:1-11.  Back to cited text no. 22
    
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Shao Z, Richie WD, Bailey RK. Racial and ethnic disparity in major depressive disorder. J Racial Ethn Health Disparities 2016;3:692-705.  Back to cited text no. 23
    
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Dunlop DD, Song J, Lyons JS, Manheim LM, Chang RW. Racial/ethnic differences in rates of depression among preretirement adults. Am J Public Health 2003;93:1945-52.  Back to cited text no. 24
    
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

 
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