Journal of Muslim Mental Health, 1:171176, 2006

Copyright Taylor & Francis Group, LLC

ISSN: 1556-4908 print / 1556-5009 online
DOI: 10.1080/15564900600980772
Prevalence of Anxiety and Depressive
Disorders Among Primary Health Care
Attendees in Al-Nasiriyah, Iraq
A. H. HUSSEIN and A. A. SAADOON
Thi Qar Faculty of Medicine, Al-Nasiriyah, Iraq
BACKGROUND
Anxiety and depressive disorders are among the most common psychiatric
disorders seen in general practice in all regions of the world (Goldberg
& Blackwell, 1970; Institute of Medicine, 2001) These disorders are signi-
cantly disabling, causing impairments to both social and physical functioning
(Olfson et al., 1997). In the past 35 years, several studies have reported that
mental and behavioral disorders are common among patients in primary care
settings in different parts of the world. However, little is known about this
issue in Iraq and, to our knowledge, there is no published study addressing it.
During the past three decades, Iraq has witnessed many internal and
external conicts, including three wars and years of sanctions. Since 2003,
violence has been increasing throughout the country. These circumstances
have affected the Iraqi population in every domain of life with varying de-
grees of repercussion.
Primary care is the cornerstone of health care services, providing an
appropriate context for detection and management of mental disorders. Epi-
demiological studies in primary care settings have been based on three meth-
ods of identication of mental disorders: the use of screening instruments,
clinical diagnosis by primary care professionals, or by psychiatric diagnostic
interview.
Goldberg and Blackwell (1970), in one of the rst studies based on more
efcient research instruments than had been previously available, found the
conspicuous psychiatric morbidity of a London general practice to be 20%.
Since then, numerous studies of primary care patients have been conducted
throughout the world with ndings suggesting high rates of depression and
Address correspondence to A. H. Hussein, Thi Qar Faculty of Medicine, Al-Nasiriyah,
Iraq. E-mail: ahmedpsy004@yahoo.com
171
172 A. H. Hussein and A. A. Saadoon
anxiety. The World Health Organization (WHO) conducted a cross-cultural
study at 14 sites, using three methods of diagnosis: a short screening instru-
ment, a detailed structured interview, and a clinical diagnosis by the primary
care physician. Although there was considerable variation between sites, the
researchers found that overall about 24% of all patients met criteria for a
mental disorder; most commonly, depression, anxiety, and substance abuse
disorders (

Ust un & Sartorius, 1995).

A study conducted at the Kaiser Permanente Medical Center in Oakland,
California, involved 1,001 primary care patients (aged between 18 and 70)
(Olfson et al., 2000). Using a structured diagnostic interview for the American
Psychiatric Associations Diagnostic and Statistical Manual of Mental Disor-
ders, fourth edition ([DSM-IV], 1994) disorders, these authors found the rates
of generalized anxiety and major depressive disorders were 3.7% and 7.3%,
respectively, and that patients with such disorders had experienced signi-
cant impairment in social and occupational functioning (Olfson et al.).
In 1980, Harding led an examination of 1,624 primary care patients in
four countries (Colombia, India, the Sudan, and the Philippines) in testing for
psychiatric morbidity using a two-stage screening procedure (24-item Self-
Reporting Questionnaire [SRQ-24] and Present State Examination [PSE]). Two
hundred twenty-ve cases were found, indicating an overall frequency of
13.9%. The majority of those patients (79%) had depressive and anxiety dis-
orders (Harding et al., 1980). Al-Haddad, Al-Garf, Al-Jowder, and Al-Zurba
(1999) directed a study of psychiatric morbidity among Bahrainian primary
care patients using the General Health Questionnaire (GHQ) and the Hospi-
tal Anxiety Depression Scale (HAD). The overall psychiatric morbidity was
27.1% (GHQ, cutoff = 9) and 23.6% (HAD, cutoff = 11). A study of Saudi Ara-
bian primary care patients, using the PRIME-MD Patient Health Questionnaire
(PHQ) and Structured Clinical Interview for the DSM-IV (SCID) as criterion
standard for validation, found that 19.3% met the PHQ criteria for depres-
sion (Becker, Al Zaid, & Al Faris, 2002). Most recently, Daradkeh, Eapen, and
Ghubash (2005) examined the nature and prevalence of mental disorders in
primary care patients in Al Ain, United Arab Emirates. They studied 571 pri-
mary care attenders using the Primary Care Evaluation of Mental Disorders
(PRIME-MD) questionnaire. Of the subjects, 210 (37.8%) satised the DSM-IV
primary care version for mental disorders. The prevalence of depressive and
anxiety disorders were 6.1% and 9.7%, respectively (Daradkeh et al.).
Our objective was to determine (1) the prevalence of anxiety and de-
pressive disorders among primary health care patients in Al-Nasiriyah City in
Thi Qar Province, and (2) the quality of life and sociodemographic charac-
teristics of such patients.
METHODS
We conducted a cross-sectional survey from September 1, 2005, to January
1, 2006, of every tenth consecutive patient aged 16 years and older at two
Journal of Muslim Mental Health 173
primary health care centers in Al-Nasiriyah City. Two nurses were familiarized
with study protocol and supervised the sampling and data collection proce-
dures. We excluded patients who were severely ill, those with hearing and
language impairment, those already in the study from a previous visit, those
visiting the center for reasons other than health complaints (e.g., vaccinations
and certicates). Illiterate patients were not excluded, but were assisted by
the research team in completing the questionnaire. The eligible 214 subjects,
after they consented, completed the Arabic translation of the PHQ and the
WHO Quality of Life Scale (WHOQOL-100) surveys in privacy while they
were waiting to be seen by the general practitioner.
The PRIME-MD was designed by Spitzer et al. (1999) to improve de-
tection of the most common mental disorders encountered in primary care
as well as in the general population. It is a rapid procedure with demon-
strated diagnostic performance (sensitivity of 83%, specicity of 88%, and a
positive predictive value of 80%) for the diagnosis of any psychiatric disor-
der. The PRIME-MD includes self-report screening instruments and diagnostic
questions that are either semistructured interviews or self-report. The PHQ
component of the PRIME-MD is a self-report diagnostic instrument. Its use,
as translated to Arabic, has been validated in studies conducted in the United
Arab Emirates and Saudi Arabia (Becker et al., 2002; Daradkeh et al., 2005).
The WHOQOL-100 was developed cross-culturally by the WHOQOL
group program on mental health and is available in more than 20 languages
(including Arabic). It is a self-administered instrument measuring the qual-
ity of life of an individual in six domains: physical health, psychological
health, level of independence, social relationships, environment, and spir-
ituality/religious/personal beliefs. There are 24 facets covered within each
domain. Four items are included for each facet, as well as four general items
covering subjective overall quality of life and health, producing a total of 100
items in the assessment. All items are rated on a 5-point scale.
Altogether, 235 patients were approached in the two primary care cen-
ters (124 at Al Habobi primary health care center and 111 at Al-Iskan primary
health care center). Two patients were excluded because of health problems,
4 failed to complete the questionnaire, and 15 refused to participate in the
survey mainly because of time constraints. Though a sample of 200 subjects
was estimated to be sufcient for a 95% condence interval (CI), a sample
of 214 was obtained to minimize the effect of refusing attendees. We calcu-
lated frequencies and prevalence, and used chi-square values to determine
statistically signicant associations.
RESULTS
A total of 214 participated in the survey; 229 eligible primary care patients
were approached, giving a response rate of 93.4%. As shown in Table 1, the
mean age of the patients was 34.3 years (SD = 7.6), with a range of 16 to
174 A. H. Hussein and A. A. Saadoon
Table 1 Characteristics of Respondents
Variable Frequency Percentage
Age
1634 101 47.1
3554 91 42.4
55 or older 22 10.5
Sex
Male 86 40.2
Female 128 59.8
Education
Illiterate 41 19.2
Primary 79 36.9
High school 71 33.2
More than high school 23 10.8
Marital status
Married 115 53.7
Single 73 34.2
Other 26 12.1
Employment
Employed 73 34.1
Unemployed 141 65.9
67 years; 59.8% were female; 53.7% were married; 34.1% were employed;
and 19.1% were illiterate.
Table 2 relates that the prevalence of depressive disorders was 10.2%,
while the prevalence of anxiety disorders was 8.4%. Approximately 25% of
the detected cases had both disorders at the same time.
There were signicant sex (Table 3), employment (Table 4), and educa-
tion (Table 5) differences in the frequency of depressive and anxiety disor-
ders. These disorders were signicantly more frequent among women and
people who were illiterate ( p < 0.4 and p < 0.3, respectively). The quality
of life in patients with anxiety and depressive disorders was lower than those
who did not have these disorders.
DISCUSSION
The results of this study highlight the high prevalence of anxiety and de-
pressive disorders among primary care patients. These results are generally
Table 2 Relation of Diagnosis and Age
Age PHQ cases Percentage Noncases Percentage Total
1534 18 8.4 83 38.8 101
3554 16 7.5 75 35.0 91
55 or older 6 2.8 16 7.5 22
Total 40 18.7 174 81.3 214

2
= 0.84, p > 0.05. There is no statistically signicant association between age
and diagnosis.
Journal of Muslim Mental Health 175
Table 3 Relation of Diagnosis and Sex
Sex PHQ cases Percentage Noncases Percentage Total
Male 8 3.7 78 36.5 86
Female 32 15.0 96 44.8 128
Total 40 18.7 174 81.3 214

2
= 83, p > 0.05. There is a highly signicant statistical association between
sex and diagnosis.
in line with many other similar studies, including the associations with sex,
education, and employment status.
The results of this study suggest that anxiety and depressive disorders are
common among patients in primary health care centers at Al-Nasiriyah City,
and that the patients with anxiety and depressive disorders have a decreased
quality of life compared with those who do not have these disorders. Because
the study was conducted in the province center of Al-Nasiriyah, its ndings
may not be generalized to the population of the entire province, especially
the rural areas. Thi Qar Province has a population of about two million. It
includes rural, urban, desert, and marsh areas, and is considered to have the
lowest violence levels when compared to other provinces of Iraq.
Moreover, only two primary health care centers were included in this
study. Despite the systemic sampling, we cannot claim that this is a truly
representative sample of all primary care patients. Nevertheless, the study
might provide reasonably valid and reliable data on the extent of anxiety
and depressive disorders among patients in primary care settings, which may
be used as starting point for guiding the development of mental health care,
and for further research on these disorders in primary care settings as well
as at the community level.
A thorough large-scale study is recommended to explore the frequency
of presentation, method of presentation, and frequency of identication by
general practitioners of these disorders. In the face of high prevalence of
these disorders in primary care settings, raising awarness of the healthcare
providers in these settings is recommended. The accurate diagnosis and
proper treatment of patients with such disorders throughout Iraq are nec-
essary to help improve the quality of life of these patients.
Table 4 Relation of Diagnosis and Employment
Employment PHQ cases Percentage Noncases Percentage Total
Employed 15 7.0 58 27.1 73
Unemployed 25 11.7 116 54.2 141
Total 40 18.7 174 81.3 214

2
= 0.25, p > 0.05. There is no signicant statistical association between diagnosis
and employment.
176 A. H. Hussein and A. A. Saadoon
Table 5 Relation of Diagnosis and Education
Education PHQ cases Percentage Noncases Percentage Total
Illiterate 30 14.0 11 5.2 41
Primary 3 1.4 76 35.5 79
High school 2 0.9 69 32.2 71
More than high school 5 2.4 18 8.4 23
Total 40 18.7 174 81.3 214

2
= 102.7, p > 0.05. There is a signicant statistical association between diagnosis and
education.
REFERENCES
Al-Haddad, M. K., Al-Garf, A., Al-Jowder, S., & Al-Zurba, F. I. (1999). Psychiatric
morbidity in primary care. Eastern Mediterranean Health Journal, 5(1), 20
26.
American Psychiatric Association. (1994). Diagnostic andstatistical manual of mental
disorders: DSM-IV, 4th ed. Washington: American Psychiatric Association.
Becker, S., Al Zaid, K., & Al Faris, E. (2002). Screening for somatization and depres-
sion in Saudi Arabia: A validation study of PHQ in primary care. International
Journal of Psychiatry in Medicine, 32(3), 27183.
Daradkeh, T. K., Eapen, V., & Ghubash, R. (2005). Mental morbidity in primary care
in Al Ain (UAE): Application of the Arabic translation of the PRIME-MD (PHQ)
version. German Journal of Psychiatry, 8, 325.
Goldberg, D. P., & Blackwell, P. (1970). Psychiatric illness in general practice: A de-
tailed study using a new method of case identication. British Medical Journal,
2, 439443.
Harding, T. W., DeArango, M. V., Baltazar, J., Climent, C. E., Ibrahim, H. H. A.,
Ladrido-Ignacio, L., et al. (1980). Mental disorders in primary health care: A study
of their frequency and diagnosis in four developing countries. Psychological
Medicine, 10, 23141.
Institute of Medicine. (2001). Neurological, psychiatric, and developmental disor-
ders: Meeting the challenge in the developing world. Washington, DC: National
Academy Press.
Olfson, M., Fireman, B., Weissman, M. M., Leon, A. C., Sheehan, D. V., Kathol, R. G.,
et al. (1997). Mental disorders and disability among patients in a primary care
group practice. American Journal of Psychiatry, 154, 173440.
Olfson, M., Shea, S., Feder, A., Fuentes, M., Nomura, Y., Gameroff, M., et al.
(2000). Prevalence of anxiety, depression, and substance use disorders in
an urban general medicine practice. Archives of Family Medicine, 9, 876
83.
Spitzer, R. L., Kroenke, K., & Williams, J. B. W. (1999). Validation and utility of a
self-report version of PRIME-MD: The PHO primary care study. Journal of the
American Medical Association, 282, 173744.

Ust un, B., & Sartorius, N. (Eds.). (1995). Mental illness in general health care: An
international study. Chichester, England: Wiley.