Prevalence and Association between Depression and Familiar Dysfunction

Mario Joaquín López-Carbajal^[1],[2], Aurora Escamilla-Nava^[3], Evelia Ramírez-Jiménez^[4]

Abstract

Family dysfunction originates psychosocial problems and a high demand of health services. Depression, a multi-factor disease, has individual and social aspects that depend each other, forming a vicious circle. It may be possible to find an association between family dysfunction and depression. The aim of this study was to determine the prevalence and the degree of association between depression and family dysfunction, in patients attending to the outpatients’ clinic of Family Medicine at Pachuca, Hidalgo. A cross-sectional and comparative study was completed, from October 2007 to January 2008, with patients attending the outpatients’ clinic of Family Medicine in Pachuca, Hidalgo, whom agreed to answer the tests: Zung, FASES, Family APGAR and Holmes. The statistical parameters, prevalence and Odds Ratio were obtained. X2 test was applied with a confidence interval of 95%, a p<0.05 value was considered significant. One hundred fifty-five women and 100 men were included, with a mean age 34.4 ± 12.9 years. Zung test for depression showed a prevalence of 34.9%, wherein 83.1% corresponded to slight depression, 14.7% to moderate depression and 2.2% to severe depression. FASES showed 53.3% of families in the medium range. Whereas Family APGAR demonstrated a 54.1% of functional families and the test of Holmes reported 47.1% without problems and 24.7% with moderate crisis. There were no significant differences in age, occupation and gender, neither association between depression and familiar dysfunction. It is concluded that 34.9% showed some degree of depression, which varied from dysthymia to severe depression. It is suggested to carry out screening programs and to provide an early treatment.

Key words: Prevalence, Depression and Family Dysfunction

Introduction

A research published in 1989 pointed out that less than 10% of medical who get the degree of the family medicine residency diagnose and prevent the events that could alter the familiar dynamics.¹ In order to talk about dysfunctional family we must know that a "normo-functional family" is that one that is able to fulfill the assigned tasks according to the stage of life in which every family is² and every family has an internal dynamics whose function is regulating relations between its members and their needs and between them and their environment. Balance is essential for a family function.³

Currently family crises are called "critical event" and this is defined as any circumstance or life experience of the individual and/or family that causes tension and stress generating some changes.² Family dysfunction causes a large number of psychosocial problems and demand for health services.^{4, 5} From various instruments for assessing family functioning, we have for example, the Wen Shing Tseng family triaxial sorting, based on basic areas of family functionality. There are other instruments such as the family APGAR, which was introduced in 1978 by Smilkestein for exploring the family functioning; it has become obsolete in the United States of America (USA) because it is believed that the complexity of family problems cannot be accurately studied with only 5 questions, but for practical reasons some authors believe that as the single instrument it would be useless, but together with other instruments eases the objective approach on family functioning. Balanced families are prone to have the ability to cope with stress and extreme families can hardly change their functionality, remaining in the same scheme producing more stress. This vicious circle is called "family dysfunction".⁶

The word depression was instituted in medical nomenclature about the middle of XIX century⁷ and is worldwide known as one of the major health problems in general not only mentally. In Mexico the action program of the Mental Health from the Health Department consider it a priority issue since the prevalence is similar to that documented in other countries.7 Around 19 million people (1.85%) of the world population suffers from major depression, over 50% are women between 40 and 50 years according to reports of the psychiatry department of Universidad Nacional Autónoma de México (UNAM), only 1 out of 10 depressed people seeks specialized aid.⁸ In the USA 15% of the general population experience an episode of depression in their lifetime.

According to a survey by the National Mental Health Association (NMHA) it was found that 48% of participants had at least one family member or close friends who suffered depression.⁹ It’s estimated that 80% are treated in the first level of attention.⁷ Watts says that only 0.2% of patients with depression consult a psychiatrist and that depression can occur at any age, with an average of initiation at 20 years and the maximum frequency is between 30 and 60 years for women and men of 40-70 years.¹⁰ Depression is a common problem in patients with coronary artery disease, where two out of three heart attack patients referred depression symptoms^{11, 12} and other chronic degenerative diseases and terminal patients the number is similar.¹³ Winokur studies and Spitzer's ideas are reflected in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)¹⁴, where a descriptive position is adopted, establishing specific diagnoses without etiological implications.¹⁰ The International Classification of Diseases (ICD-10) divides them into a single or recurrent episode and classified them according to the upset intensity.¹⁵ Depression is a mood disorder part of organic psychiatric disorders. The most common symptoms are indifference or apathy, irritability, fatigue, poor concentration, guilt feelings, changes in neurovegetative functions such as sleep patterns and appetite, apathy, anhedonia, inability for solving problems, decreased libido, indecisiveness in decision-making, absenteeism and thoughts of death.^{16, 17}

The priority is given to the diagnosis of depression in primary care and this leads to the research and development of short detection tools that do not require the participation of a clinical mental health specialist.^{18, 19} In this sense there is a depression scale of the Center for Epidemiologic Studies (CES-D), which is applied to general population, it’s self-administered and has 20 items.²⁰ Another test is the Hamilton depression scale, which must be applied by a clinician and has 17 items.²¹ The Montgomery-Asberg scale applied by the clinician consists of 10 items. Raskin scale which is exclusively for hospitalized. The Beck questionnaire is self-administered but mentions that it is more feasible in psychiatric patients. The Zung scale is self-administered with 20 items, direct questions and easy to answer by the population in general and time to be answered and evaluated is too brief.²² Carroll scale for depressed patients with 52 items and finally the Golberg that aims to detect patients in the family or general medicine external consultation.²⁰

In 1953 Wolf highlighted the importance of stressful life events as precipitating disease. This theory emphasizes the use of controlled methodological techniques to measure the relationship between stressful stimulus and physiological variables, but over than stress nature is important the meaning each individual gives to it and capabilities which has to handle and adapt. The vulnerability and stress resistance may be affected by the presence or absence of "social buffers" which protect against the emotional instability and psychosomatic illness. In this regard, Dr. Palomar noted that alcoholism is associated with low levels of communication and family cohesion as well as lack of adjustment and personal and social well-being.²³ Some argue that life events (change of residence, serious illness, divorce or separation, job loss, retirement, a close relative or friend death, kidnapping of a relative or friend) that is defined as any incident that occurs in the external environment of the individual, would explain the high prevalence of depression in poor countries.²⁴

For this study, given its feasibility, we applied the following test: to measure depression: Zung and Colmes and to measure family function: PHASES III and Single Family APGAR; all of them already validated in multiple investigations.

Depression is a multifactorial disease that is poorly understood where individual and social aspects are involved which depend on each other forming a vicious circle. Besides the diagnosis underreporting of this disease in the Family Medicine external consultation makes its real prevalence unknown.

Based on the above and considering the family as the basic cell of society, we assume that there is an association between depression and family dynamics, being feasible to measure both by tests already validated. The present study is aimed to determine the prevalence of depression and family dysfunction, and the association degree in patients attending the external consultation at the IMSS Family Medicine in Pachuca, Hidalgo.

Material and Methods

We performed a comparative cross-sectional study in the Instituto Mexicano del Seguro Social Zone General Hospital No. 1 in Pachuca, Hidalgo (HGZ No. 1 IMSS) from October 2007 to January 2008. The study protocol was approved by the Institutional Committees and the study was conducted according to the Regulations of the General Health Law in the field of Health Research and the Helsinki Declaration. Instruments were self-administered. The information was also obtained from other variables such as age, gender, schooling, occupation and the presence of other associated diseases, among others. We included patients at random who attended the Family Medicine external consultation, of both genders, aged 16 years and less than 80 years, who agreed to participate in the study by answering more than 90% of the following tests: ZUNG, PHASE III, Family APGAR and HOLMES. Those who had a mental illness or who were under psychological treatment were excluded.

The information was captured in a database and analyzed using the version: 11.0 SPSS statistical program. We performed univariate and bivariate analysis. Frequencies, percentages, averages and standard deviation were obtained. To find the connection of depression with family dysfunction, we obtained odds ratios (OR) as an estimate of the prevalence ratio (PR) with confidence intervals at 95% (IC95%). X² was applied with ​​p <0.05 significant values.

Results

15 tests from the 270 performed tests were eliminated for obvious errors or incomplete information at filling them, so that the results reported correspond to 255 surveys. Table 1 demonstrates the participants sociodemographic characteristics. The age range varied from 16 to 72 years. According to the Zung test, the prevalence found in the participating patients was 34.9%. When classifying the data we found that depression was higher in women than in men and the highest percentage was mild (Table 2).

The FACES III Test Circumflex Model, allowed us to measure Family Cohesion; finding that the one who got the highest score was the connected family (see Figure 1). Regarding the adaptability, we found the chaotic family prevailed (see Figure 2). By combining the FACES III test cohesion and adaptability results, we classified family functioning and found that the midrange type prevailed (see Figure 3).

Table 1. Interviewed patients characteristics

The Individual APGAR showed that 138 patients (54.1%) consider their family as functional, 117 (45.9%) had moderate dysfunction and was not found any severe.

Figure 1. Family Cohesion in participating patients according to FACES III evidence.

Finally, the HOLMES test described 120 beneficiaries (47.1%) without crisis, 63 (24.7%) with moderate crisis, 48 (18.8%) with mild crisis and 24 (9.4%) with severe crisis. The bivariate analysis showed that probably the risk of depression increases when family dysfunction, although the result was not significant: OR = 1.296 (95% IC_95%0653-2.573; X²0.55; p=0.46).

Table 2. Classification of depression, according to Zung test, in interviewed patients.

Figure 2. Family Adaptability in interviewed patients according to FACES III evidences.

Discussion

The depression overall prevalence among the surveyed population was 34.9%. At first, it was corroborated the hypothesis that there is significant underreporting of this disease. Moreover, this frequency is similar to other studies of patients treated in the first level of attention.^{7, 9} Perhaps resulting high prevalence, but our results are consistent with other studies, which report ranging from 2.7% to 34% prevalence. This allows us to see that there is great variability due to the difficulty to measure depression, because it depends on qualitative and subjective aspects, which can easily modify responses, it could even depend on the patient mood at the time of the interview, as he/she can answer it depressed, without actually suffering the condition.

Figure 3. Classification of family functioning according to FACES III testing in patients

Due to the large influx of patients in some centers, we often overlook some tools we have and whose application can guide or confirm some diagnostic suspicions, in tables mainly stem from psycho-social problems.²⁰ As noted, there are few investigations that have linked family functioning, which are understood by family behavioral patterns in dimensions such as cohesion, communication, roles, the power structure, conflict resolution, the expression of affection and behavioral control, with quality of life and wellness. Type of origin family, mental health, locus of control, self-esteem, personal competence and achievement orientation or stress, among many others are mentioned as aggravating.^23-27 Other authors have made trials where observed high rates of possible emotional disorder and depressive and somatic symptoms, many depression risk factors such as low self-esteem, stress, experiences of sexual abuse, alcoholism and possible affective problems of origin family.^{23, 25, 28, 29}

We found some problems when applying the PHASES III test because some items are in content, not in the composition. For this reason, many respondents apparently were confused. On the other hand, we recommend to test it in families with children because it has items that question their discipline, so if they are not answered, the scores will be very low, which doesn’t mean to be a dysfunctional family. In families with children aged less than five years, is the same situation because they cannot assess the discipline used on them.

Finally, we believe that complete four questionnaires at the same time was valuable because it gave us a lot of information, it allowed contrasting and measuring questions but it is annoying for those who answered, so I suggest to use a test for depression and another for family functionality.

Conclusions

This study allowed meeting the objectives. There was a prevalence of depression of 34.9%, ranging from dysthymia to severe depression. No significant differences were found for age, gender, schooling or occupation.

When answering the APGAR, it was found that 54.1% of people show that the family who they live with is functional and the PHASE III test found that 53.3% show midrange family, but that does not mean that they don’t have adaptability or communication problems, but for the time of the life cycle in which they live are operating as a nucleus. Based on the above, given that depression is a common condition, with high demand for health services, because of family and psychosocial problems, we consider it appropriate the Zung testing as early detection, in order to implement an appropriate treatment and avoid serious consequences.

Finally, we can say that the study showed a likely increase in the risk of depression when living in dysfunctional families, although this result was not statistically significant.

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^[1]Hospital General de Zona No.1, IMSS, Pachuca, Hidalgo

^[2]Academic Area of Medicine, ICSa, UAEH. Tilcuautla, Hidalgo

^[3]No. 6 Zone General Hospital, IMSS, Tepeji del Río, Hidalgo

^[4]Medicine Family Unit No. 93, IMSS, Ecatepec, Estado de México.

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