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DEPARTMENT of CLINICAL NEUROSCIENCE Karolinska Institutet, Stockholm, Sweden DEPARTMENT OF CLINICAL NEUROSCIENCE Karolinska Institutet, Stockholm, Sweden and DEPARTMENT OF PSYCHIATRY Makerere University, Kampala, Uganda The Interface between Family Structure, Life Events and Major Depression in Uganda Wilson Winstons Muhwezi MAKERERE UNIVERSITY Stockholm and Kampala 2007 All previously published papers were reproduced with permission from the publishers. Published by Karolinska Institutet and Makerere University. Printed by Intellecta Docusys AB, Hulda Mellgrens gata 1C S-421 32 Västra Frölunda. © Wilson Winstons Muhwezi, 2007 ISBN 978-91-7357-393-1 Cover Picture: A caregiver interview, one of the health centres and a fieldwork scenery. To Salome Bergen, Noble and Trust ABSTRACT Background: Poor detection of depression in primary health care is universal but worse in resource-constrained societies, yet the illness must be recognized first if it is to be appropri- ately managed. While current debates about life events in Western societies is on their role in the gene-environment interaction to cause depression, research on the interface between life events, family structure and major depression in many developing countries is still rare. Prevention of depression by preventing life events may not be feasible but knowing depres- sogenic life events is a cue for rapid intervention. Aim: To describe the feasibility of detecting current major depressive episodes (MDEs) in physically ill patients, identify life events associated with the MDEs, describe the interaction between life events, family structure and MDEs, and to explore how patients’ caregivers perceive such depression. Methods: Consecutive outpatients at three PHC centres were interviewed in each of the first three studies. A cross-section of 199 physically ill patients (74 with DSM-diagnosis of major depression and 125 without) were the respondents in the study for Paper I. A case control research design was used for Paper II to compare life event experiences of the 74 physically ill and depressed patients with 64 general population controls and for Paper III in which comparison was between 85 depressed and 170 non-depressed physically ill patients. The study for Paper IV used a qualitative approach to interview 29 adult caregivers of physically ill patients that were depressed. Main findings: In Paper I, it is demonstrated that four simple subjective well-being questions could predict successfully the presence of a current major depressive episode. Paper II shows that losses related to interpersonal relationships and work as well as health and bereavement-related life events were predominant among patients with major depressive episodes. In spite of the buffer provided by the family, life events related to work, education, health and courtship/cohabitation significantly had more negative impact ratings among the depressed. Independent life events clustered around work, health, bereavement and marriage were associated with an increased risk of major depressive episodes in patients compared to controls. Similarly, findings in Paper III show that depressed patients from extended families experienced significantly more negative life events related to loss and bereavement. Distressing and bereavement-related life events were predictors of depression among patients from extended families. Given the concealment of depression in physical illness, caregivers could not identify the depressive episodes thereby undermining appropriate care-giving (Paper IV). However, they identified and associated a number of life experiences to what they referred to as ‘thinking a lot’. Care-giving was found to be challenging. Conclusions: Four simple questions reflecting subjective well-being appear to have the potential to detect diagnosable patients likely to have a current major depressive episode. While the extended family is often assumed to cushion members from shocks of stressful life events, it appears to be weakening and unable to protect at risk individuals from developing depression. Psychosocial interventions as well as training and deployment of mental health workers in communities to promote coping are needed. Caregivers deserve support since their physical, psychological, economic and social resources are necessary in management of depression yet, such resources are being drained. Key Words: Depression, subjective well-being, current major depressive episode, major depressive illness, screening, primary health centre, Uganda, Africa, life events, life stories, family structure, caregivers, informal care-giving, coping. LIST OF PUBLICATIONS This thesis is based on the following papers, which are referred to by their Roman numerals. The four papers put together present the results that arose out of an investigation into the interface between family structure, life events and major depression in central Uganda. I. Muhwezi, W. W., Ågren, H., & Musisi, S. Detection of major depression in Ugandan primary health care settings using simple questions from a subjective well-being (SWB) subscale. Soc Psychiatry Psychiatr Epidemiol, 2007: 42(1), 61-69. II. Muhwezi, W. W., Ågren, H., Neema, S., Maganda, A. K., & Musisi, S. Life events associated with major depression in Ugandan Primary Health Care (PHC) Patients: Issues of cultural specificity. Accepted in June 2007 for publication by International Journal of Social Psychiatry. III. Muhwezi, W. W., Ågren, H., Neema, S., Musisi, S., & Maganda, A. K. Life events and depression in the context of the changing African family: The case of Uganda. World Cultural Psychiatry Research Review (Official Journal of the World Association of Cultural Psychiatry), 2007 Jan:10-26. IV. Muhwezi, W. W., Okello, E. S., Neema, S., & Musisi, S. Caregivers’ perceptions concerning the interface between life events and major depressive illness as seen among patients at Primary Health Care Centers in Central Uganda. Submitted Manuscript to Qualitative Health Research in July 2007. CONTENTS 1. BACKGROUND ..................................................................................................................... 1 1.1 DEPRESSOGENIC EFFECTS OF LIFE EVENTS....................................................................... 1 1.2. DEFINITION OF ‘LIFE EVENTS’............................................................................................ 3 1.2.1. Stressful Life Events...................................................................................................... 3 1.2.2. Scaling of Life Events ................................................................................................... 3 1.3. DEVELOPMENT OF THE TERM ‘DEPRESSION’ ..................................................... 4 1.3.1. Depression: The Global Context.................................................................................. 6 1.3.2. Depressive Illness in Africa.......................................................................................... 7 1.3.3. Depressive Illness in Uganda....................................................................................... 7 1.3.4. Primary Health Care (PHC) and Depression ............................................................. 7 1.4. LIFE EVENTS, FAMILY STRUCTURE AND DEPRESSIVE ILLNESS .......................................... 8 1.4.1. The Family in Africa and Healthcare .......................................................................... 8 1.4.2. Family Dynamics, Life Events and Major Depression................................................ 9 2. THEORETICAL FRAMEWORK ..................................................................................... 10 2.1. A CONCEPTUAL MODEL.................................................................................................... 10 2.2. STRESS ............................................................................................................................. 11 2.3. STRESS AND LIFE EVENTS................................................................................................ 11 2.4. COPING WITH LIFE EVENTS AS STRESSORS ....................................................................... 12 3. AIMS OF THE STUDY........................................................................................................ 14 3.1. GENERAL AIM.................................................................................................................. 14 3.2. RESEARCH QUESTIONS ..................................................................................................... 14 3.3. SPECIFIC OBJECTIVES OF THE STUDIES ............................................................................. 14 4. METHODS USED IN THE STUDY .................................................................................. 15 4.1. INTRODUCTION................................................................................................................. 15 4.2. THE STUDY CONTEXT AND SETTING ............................................................................... 15 4.2.1. Uganda: Location, Brief History, People and Socio-Demographics ....................... 15 4.2.1.1. The Location and Geography of Uganda ...................................................... 15 4.2.1.2. A Brief History of Uganda............................................................................... 17 4.2.1.3. The Peoples of Uganda..................................................................................... 18 4.2.1.4. The Baganda ....................................................................................................
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