Depression literacy and the related factors among a group of hospitals’ staff in Iran

Abstract

Background:

Having a proper approach to depression requires having sufficient depressive literacy in the affected person.

Aims:

This study aimed to evaluate the level of depression literacy among hospital staff affiliated to Isfahan University of Medical Sciences (IUMS) and to reveal the risk factors and knowledge gaps.

Methods:

This was a cross-sectional study with 760 participants from university hospital staff at IUMS who were selected by a census method from April 2018 to December 2018. The data regarding depression signs and symptoms, anti-depressant drugs safety, non-medical treatment efficacy, etc. were collected using the Depression Literacy Questionnaire (D-Lit-22) and were analysed by SPSS-20, using the Pearson correlation coefficient, independent Samples t-test and analysis of variance (ANOVA) (p ⩽ .05).

Results:

The mean age of participants was 35.33 ± 8.00 years old and 77.6% of them were female. The mean of the total score of depression literacy was 11.62 ± 3.53. Depression Literacy score was significantly higher in those with higher education levels, female gender and clinical staff (p < .001). The inability to distinguish depression from other mental disorders as well as having wrong beliefs about suitable treatment approaches were the most considerable gaps in depression literacy.

Conclusion:

Male gender, low level of academic education and working in non-medical wards are the main factors associated with lower depression literacy in our studied sample. The poor differentiation of depression and wrong beliefs in depression treatment modalities were the largest gaps which require more educational programmes.

Keywords

Depression depression literacy mental health literacy medical staff

Introduction

Depression is a common mental disorder that causes suffering from feelings such as tiredness, loss of appetite, grief, guilt, inability to concentrate, sadness and loss of motivation in performing usual activities, among others. This mental disorder can even lead to suicide in extreme cases (Kessler & Bromet, 2013; Mathers & Loncar, 2006).

According to the World Health Organization, over 300 million people worldwide are suffering from severe depression. Moreover, depression accounts for 800,000 deaths due to suicidal attempts annually (World Health Organization, 2017). Depression is the second most common cause of disability-adjusted life year in the world after cardiovascular diseases by 2020 (Murray et al., 2007). However, investigations have not shown any increase in patients seeking mental health care in the last 10 years (Alaghehbandan et al., 2005; Wang et al., 2005). Accordingly, the evidence highlights the need to take immediate actions to diagnose, manage and prevent this psychological state.

Lack of knowledge and having misconceptions about depression aetiologies and stigma, as well as the refusal of evidence-based mental health care are serious limitations for providing appropriate professional support to patients (Jorm, 2000).

Mental health literacy is defined as the knowledge and beliefs about mental disorders that affect the recognition, prevention and management of such conditions. According to the literature, inappropriate mental health literacy among people causes delayed help-seeking, irregular follow-up, and discontinued or interrupted treatment (Jorm, 2000). Although Canadian mental health organisations emphasise on improving public knowledge and attitudes, this issue is neglected in many societies (Sénat, 2006).

Depression Literacy, as a concept of how many people in the community know about the primary signs and symptoms of depression and the ways of approaching this medical condition, has attracted the attention of researchers from Canada and Australia and coherent schedules have been planned by Australians to improve depression literacy over the past decade (Jorm et al., 2003; Parslow & Jorm, 2002; Sénat, 2006). In a narrative review, Jorm AF reported that 67.3% of the study population were able to recognise depression symptoms. In this study, 59.9%, 28.9% and 23.4% of participants mentioned family physicians or general practitioners in primary care centres, counsellors, friends and family members, respectively, in response to the question about the most efficient person for the treatment of depression. When the participants were asked about the effects of therapeutic modalities, 47.8%, 50.4% and 92% of them acknowledged the suitability of anti-depressants, the efficacy of vitamins and minerals, and the effectiveness of exercise, respectively. In addition, only 44.4% and 16.7% of participants respectively reported psychotherapy and psychiatric techniques as necessary treatments for depression (Jorm et al., 2006). These attitudes can seriously disrupt the primary prevention and treatment of depression; moreover, it can be an alarming sign to other societies.

Based on community-based investigations, women more frequently experience depression than men (Kessler et al., 2003; Patten et al., 2006). Besides, women are more willing to seek professional help than men (Vasiliadis et al., 2005) while men have more tendency to substance abuse compared to women (Wang & El-Guebaly, 2004). These findings indicate a wide gap in the knowledge and attitudes of males and females regarding depression and its associated treatment necessities and modalities.

Another study on a group of adults with untreated mental health problems showed that females and young participants had higher depression literacy. Additionally, higher depression literacy was associated with fewer requests for informal treatments (Tomczyk et al., 2018). Tabaei et al. (2010) evaluated the knowledge and attitude of families with patients suffering from major depression and found that 56% of these families had a satisfactory level of knowledge that was affected by age and education status.

Based on the clinical observation of the authors, hospital staff, especially nurses, are trustworthy individuals in the view of general public with whom others can consult regarding health problems in Iranian society. Therefore, their knowledge and attitude determine the approaches people take to mental illnesses, such as depression. With this background in mind, the present study aimed to assess depression literacy in Isfahan University of Medical Sciences hospital staff to elaborate if the hospital staff depression literacy is acceptable for giving a proper consultation to the general population.

Methods

This cross-sectional study was conducted on 760 hospital staff, including workers from outpatient clinics and various inpatient hospital wards that are affiliated to Isfahan University of Medical Sciences, Isfahan, Iran. Participants were selected by a census method from April 2018 to December 2018. Workers in different sections of the mentioned university hospitals (e.g. nurses, laboratory workers, midwives, operating room personnel, employees, hospital guards and any other non-medical and service centre workers) who were willing to participate in the study were included in this research.

The Ethics Committee of Isfahan University of Medical Sciences approved this study: IR.MUI.MED.REC.1396.971

In the present study, depression literacy measured by the Depression Literacy Questionnaire (D-Lit-22). This instrument comprises 22 items about depression symptoms and its differential diagnosis and management approaches. In this questionnaire, participants should select one of the three options of ‘Yes’, ‘No’ or ‘I do not know’ in response to each item. The answers were rated by assigning one score to each correct answer. The score ranged between 0 and 22 with higher scores representing higher levels of depression literacy. Griffith et al. initially designed D-lit-22 and the internal consistency and test-retest reliability of this questionnaire were reported 0.70 and 0.71, respectively (Griffiths et al., 2004; Gulliver et al., 2012).

Due to the unavailability of the Persian version of the questionnaire, the English version was translated, and validated by a team of three psychiatrists and psychologists before conducting the research using forward and backward translation procedures. Test-retest reliability of 0.75 was obtained by administering this questionnaire to 20 medical students.

The researcher asked subjects to inquire about any parts that were ambiguous during the completion of the questionnaire. The questionnaires with the flaw rate higher than 20% were excluded from the final analysis. The participants’ levels of education were considered in three levels: up to bachelor, bachelor, master and above. In addition, the occupation was taken into account as clinical or non-medical categories. People who were in direct contact with patients, such as nurses, operating room staff, and midwives were considered as medical staff and other participants as non-medical staff.

We innovatively divided the D-Lit-22 items into three subgroups as the Diagnostic (2,4,7,8,9,11), Differentiator (1,3,5,6,10) and Management items (12,14,16-22). Items 13 and 15 were not included in any category.

Statistical analysis

The data were analysed in SPSS software, version 20, using Pearson’s correlation coefficient, Independent Samples t-test, and ANOVA. A p-value of less than .05 was considered statistically significant.

Results

Seven hundred and fifty-three university hospital staff participated in this study with a mean age of 35.33 ± 8.00 years. 77.6% of the participants were female. Seven incomplete questionnaires were excluded from the study.

Table 1 shows the demographic characteristics of the participants.

Table 1.

Demographic characteristics of the participants.

		Frequency	Percentage
Gender	Male	168	22.4
Gender	Female	582	77.6
Level of Education	Up to bachelor	177	23.5
	Bachelor	522	69.3
	Master and above	54	7.2
Hospital	Khorshid	81	10.8
	Beheshti	26	3.5
	Alzahra	368	48.9
	Kashani	47	6.2
	Imam Hossein	141	18.7
	Amin	90	12.0
Job	Medical staffs	509	67.6
Job	Non-medical staff	243	32.4

Table 2 illustrates the percentage of participants’ responses to each item of depression literacy questionnaire

Table 2.

Percentage of participants’ true answers to each items of depression literacy questionnaire.

1.	People with depression often speak in a rambling and disjointed way.	31.7
2.	People with depression may feel guilty when they are not at fault.	81.1
3.	Reckless and foolhardy behaviour is a common sign of depression.	48.2
4.	Loss of confidence and poor self-esteem may be a symptom of depression.	85.7
5.	Not stepping on cracks in the footpath may be a sign of depression.	44.5
6.	People with depression often hear voices that are not there.	42.4
7.	Sleeping too much or too little may be a sign of depression.	85.8
8.	Eating too much or losing interest in food may be a sign of depression.	85.3
9.	Depression does not affect your memory and concentration.	72.2
10.	Having several distinct personalities may be a sign of depression.	29.1
11.	People may move more slowly or become agitated because of their depression.	79.7
12.	Clinical psychologists can prescribe antidepressants.	52.1
13.	Moderate depression disrupts a person’s life as much as multiple sclerosis or deafness.	47.1
14.	Most people with depression need to be hospitalised.	63.6
15.	Many famous people have suffered from depression.	38.4
16.	Many treatments for depression are more effective than antidepressants.	11.6
17.	Counseling is as effective as cognitive behavioral therapy for depression.	3.3
18.	Cognitive behavioural therapy is as effective as antidepressants for mild to moderate depression.	69.9
19.	Of all the alternative and lifestyle treatments for depression, vitamins are likely to be the most helpful.	22.2
20.	People with depression should stop taking antidepressants as soon as they feel better.	74.5
21.	Antidepressants are addictive.	32.2
22.	Antidepressant medications usually work straight away.	22.2

The mean score of the D-lit questionnaire in the studied sample was 11.62 ± 3.53 (Min = 0, Max = 20). The correlation coefficient of age and depression literacy scores was 0.04 indicating no significant relationship between these two variables (p = .21).

Table 3 represents depression literacy mean scores by gender, education, hospital and job.

Table 3.

Comparison of the depression literacy mean score ± standard deviation (SD) based on assessed variables.

Variable		Depression literacy mean score	SD	p-value
Gender	Male	10.76	3.75	<.001
Gender	Female	11.87	3.43	<.001
education	Up to bachelor	9.88	3.36	<.001
	bachelor	12.00	3.40
	Master and above	13.68	3.05
Hospital	Khorshid	13.11	3.12	.003
	Beheshti	10.69	2.83
	Alzahra	11.41	3.63
	Kashani	11.56	3.20
	Imam Hossein	11.43	3.56
	Amin	11.74	3.46
Job	Medical staffs	12.22	3.39	<.001
Job	Non-medical staff	10.29	3.47	<.001

Table 4 presents the distribution of the responses to D-Lit-22 items by the three subgroups of diagnostic, differentiator and management subscales.

Table 4.

True answers to diagnostic, differentiator and management items of depression literacy questionnaire.

Diagnostic items	True answers	Mean
People with depression may feel guilty when they are not at fault	81.1%	81.6%
Loss of confidence and poor self-esteem may be a symptom of depression	85.7%
Sleeping too much or too little may be a sign of depression	5.8%
Eating too much or losing interest in food may be a sign of depression	85.3%
Depression does not affect your memory and concentration	72.2%
People may move more slowly or become agitated because of depression	79.7%
Differentiator items
People with depression often speak in a rambled and disjointed way	31.7%	39.2%
Reckless and foolhardy behaviour is a common sign of depression	48.2%
Not stepping on cracks in the footpath may be a sign of depression	44.5%
People with depression often hear voices that are not there	42.4%
Having several distinct personalities may be a sign of depression	29.1%
Management items
Clinical psychologists can prescribe antidepressants	52.1%.	43.5%
Most people with depression need to be hospitalised	63.3%
Many treatments for depression are more effective than antidepressants	11.6%
Counseling is as effective as cognitive behavioral therapy for depression	3.3%
Cognitive-behavioural therapy is as effective as antidepressants for mild to moderate depression	69.9%
Of all the alternative and lifestyle treatments for depression, vitamins are likely to be the most helpful	22.2%
People with depression should stop taking antidepressants as soon as they feel better	74.5%
Antidepressants are addictive	32.3%
Antidepressant medications usually work straight away	61.9%

Discussion

This study aimed to determine depression literacy in hospital staff affiliated to Isfahan University of Medical Sciences. Generally, 52.8% of the questions were answered correctly. The total mean score of depression literacy was 12.22 ± 3.39 in medical and 10.29 ± 3.47 in non-medical staff.

In a general population-based study performed in Canada, participants correctly answered to 67% of the questions measuring literacy about depression (Oliffe et al., 2016). In another study conducted in India, about 57% of healthcare students in a tertiary care centre gave correct answers to questions about the signs and symptoms of depression (Ram et al., 2017).

According to our investigations, there no study assessed depression literacy in the general population of Iran. Based on our findings, it could be claimed that the mean depression score obtained in this study for university hospital staff is lower than that of the general population in Canada and healthcare students in India.

Most people in Iran are family-oriented, the family is the most effective support system, and they seek help from family members or friends who work in health care systems before referring to a doctor (Kleinman et al., 1982). Therefore, the knowledge and attitude of these people are highly influential in the treatment of psychiatric illnesses such as depression. Accordingly, low depression literacy among the health system staff might be a major challenge in the Iranian population.

In this study, medical staff and those with higher levels of education had significantly higher depression literacy scores than those with lower levels of education and non-medical staff. This finding is justifiable because formal education and knowledge shared among colleagues can contribute to this knowledge. Also, females had higher depression literacy scores, compared with males, which is in line with the results of many other studies (Oliffe et al., 2016; Ram et al., 2017; Singh et al.., 2019). Similarly, Townsend et al. (2019) reported that women obtained higher depression literacy scores than men after a Universal Depression Education Programme.

In two review studies investigating gender differences in health literacy of migrants and depression literacy among adolescents, females had higher depression literacy scores (Aldin et al., 2019; Singh et al., 2016). The aforementioned evidence shows the higher risk of poor health literacy in men and the importance of focusing on men in planning for health-related educational programmes.

The categorised analysis of Depression Literacy Questionnaire items showed that 81.6% of the participants answered correctly to the questions about the common signs and symptoms of depression.

In numerous studies, recognising the main signs and symptoms of depression has not been a challenge and most participants pointed to the diminished interest in activities, weight loss and insomnia, sense of worthlessness and suicidal thoughts as the main signs and symptoms of depression (Aluh et al., 2018; Bruno et al., 2015; Coles et al., 2016).

In this study, the mean scores of correct answers to questions about the differentiation of depression from other mental illnesses were prominently lower than those of recognising the main signs and symptoms (39.2% vs 81.6%) of depression (Table 4).

Differentiating mental disorders is a complex phenomenon and requires special education and skills. However, it remains unclear whether the ability to differentiate various mental disorders by the general population is beneficial. Another aspect is the potential benefits of this point for early recognition or treatment and socioeconomic aspects of mental disorder management. There is still a lack of evidence in this area; however, this is not as important as the knowledge regarding the main signs and symptoms of depression for the general population. Nonetheless, this should not be ignored as well.

Despite the similarities in percentages of correct answers to questions about major signs and symptoms of depression, greater differences were found in percentages of correct answers to the questions about the differentiation of depression from other mental disorders and managerial ways (Table 4).

Only 52.1% of participants answered correctly to the item of ‘clinical psychologists can prescribe antidepressants’; in other words, 47.9% of them did not know the exact role of a clinical psychologist in the management of mental disorders. This attitude can hinder a depressed person from seeking help from a clinical psychologist.

Moreover, 11.6% and 3.3% of the participants respectively gave correct answers to the items of ‘Many treatments for depression are more effective than antidepressants’ and ‘Counseling is as effective as cognitive behavioral therapy for depression’. These rates indicated that the participants’ knowledge about the available and effective treatment is far from reality.

A study conducted on patients with depression reported the existence of many erroneous beliefs about antidepressant drugs among the participants (Demyttenaere et al., 2004). In another study on these patients, only 40% of the participants considered antidepressant drugs useful (Goldney et al., 2001). In several studies, the lack of knowledge about the present treatments was the most frequent reason for delaying or not seeking professional help or treatments (Spedding et al., 2014).

The findings of the present research and some previous studies regarding the treatment modalities of depression are suggestive of another important gap in depression literacy among the general population and health workers.

Approximately, 88% of our participants believed that of all the alternative and lifestyle treatments for depression, vitamins are likely to be the most helpful. Vitamin therapy for depression is a common approach among the public in many societies (Spedding, 2014). In a systematic review, some cross-sectional and epidemiologic studies, but not all studies, reported an association between low levels of vitamin D and depression (Sánchez-Villegas et al., 2009). In another study, low folate intake was associated with depression among male smokers, and a low intake of vitamin B₁₂ was related to depression among women. However, vitamin B₆ was not reported to be associated with depression (Williams et al., 2005).

There are many studies regarding the association of folate, vitamin D and group B vitamins with depression. However, the results of systematic reviews indicated the lack of well-documented findings of the role of vitamins in the treatment of depressed patients (Williams et al., 2005; Zahedi et al., 2019). Despite such scientific findings, about 88% of our participants believed that among all the alternative and lifestyle treatments for depression, vitamins are likely to be the most helpful. Such misinformation of the university hospital staff who are potential counsellors for the general population is a serious pitfall in our health system.

Correct views to the item ‘Antidepressants are addictive’ was 32.3% in our study. In a study on nurses in Bangladesh, only 35% of the subjects correctly answered this item (Mali et al., 2018). This means that 67.7% of our participants and 65% of Bangladeshi nurses believe that antidepressant medicines are addictive. According to Jouhar, although some of the available antidepressants have some withdrawal signs and symptoms, current findings cannot label antidepressants as addictive medicines (Baldwin et al., 2019).

The rates of the correct answer to the ‘Duration of action of antidepressants’ in our population and Bangladeshi nurses were 61.9% and 51.7%, respectively. Concerning ‘the stopping time of antidepressants’, these rates were 58.1% and 74.5% respectively (Baldwin et al., 2019). Beliefs like ‘antidepressant medicines are addictive’, ‘rapid onset of antidepressant effects’, ‘many other treatments for depression are more effective than antidepressants’, and ‘people with depression should stop taking antidepressants as soon as they feel better’ might be disruptive for the continuous effective treatment of depression.

Limitations: Ignoring the items such as exposure to mental health literature, family history of depression, depression history of the near and dear ones as the factors that might influence the level of literacy are among the main limitations of the study.

Conclusion

Being a male, having a low level of education, and working in non-medical wards are the main factors associated with lower depression literacy in hospital staff. The most important information gap which needs to be prioritised in educational programmes is related to differentiating signs and symptoms of depression.

Suggestions: It is essential for health system managers to pay more attention to the status of mental health and depression literacy (as the most prevalent and disabling mental disorder) in health system workers and to design educational interventions for them and the general population.

Footnotes

Acknowledgements

We hereby appreciate all the participants of this study for their genuine cooperation in data collection and our appreciations also go to the Vice-chancellor for Research of Isfahan University of Medical Sciences for funding this research.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Gholam Reza Kheirabadi

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