Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
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Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




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Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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I wish JCDR a great success and I hope that journal will soar higher with the passing time."



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Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




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Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2009 | Month : December | Volume : 3 | Issue : 6 | Page : 1859 - 1866

Risk Factors For Depression; Findings Of A Descriptive Study Conducted In Penang, Malaysia

KHAN T M *, SULAIMAN SYED A S**, HASSALI M A***

*School of Pharmaceutical sciences, University Sains Malaysia 11800,Pulau Penang,*School of Pharmacy, Island College of Technology, Balik Pualu 11000,Pulau Penang.*** Discipline of Social and Administrative Pharmacy, School of Pharmaceutical sciences, University Sains Malaysia 11800,Pulau Penang

Correspondence Address :
Tahir Mehmood Khan [Ms Clinical Lecturer,Department of Pharmacy Lecturer Island College of technology 11000, Balik Pulau, Penang, Malaysia Email: tahirmehmood@kict.edu.my tahir.pks@gmail.com

Abstract

This study aims to provide data on the prevalence of depression and the possible risk factors responsible for its prevalence. A descriptive, retrospective and prospective evaluation of the medical records was done at the psychiatry OPD, Penang, GH, from Jan 2002 till Dec 2007. The data was analyzed by using the statistical software, SPSS version 13®. A total of 298 patients with a confirmed diagnosis of depression, were the part of study. The prevalence of depression was found to be statistically significant among females (X2 =216.5, df =2, p=<0.001), as a majority [169(56.7%)] of the patients were females. In terms of ethnic groups, 172(57.7%) patients were Chinese (X2 =1951.5, df =5, p=<0.001. However, in terms of age majority, 121 (40.6%) patients were over 50 years of age (X2 =128.0, df =7, p=<0.001). Whilst evaluating the risk factors for depression, it was revealed that depression due to medical complications and social problems were the common identified stressors during patient evaluation. The most prevalent medical complication was hypertension. Among social issues, marital and family problems, followed by relationship/childhood problems and death of loved ones, were the frequent risk factors identified among females. However, financial and the job related problems were the most common stressors identified among males. Overall, the findings demonstrated that Chinese patients were at a high risk of depression among the elderly patients with medical complications.

Keywords

Depression, Risk factor, Medical complications


Depression is the state of gloomy thoughts characterized by sadness, loss of interest in activities and decreased energy (1). An ancient text in Ebers Papyrus, 1974, presented a short description of depression among Egyptians (2). History demonstrated different concepts among people and cultures about depression. However, in 1950, chemical imbalances in the brain were perceived to be the possible cause of depression; this hypothesis was presented whilst observing the effects of reserpine and isoniazid in altering the levels of monoamine and by observing the corresponding depression symptoms (3).

In today’s busy life, depression is one of the most prevalent psychological disorders (4) which is a challenge to public health (5). According to “WHO”, by the year 2020, depression is expected to become the second leading cause of disability after heart disease (7). The population in developing countries is at a greater risk (6). So far, it has been very hard to point out a single reason as the cause of depression. Josef et al., in 2006, stated that the prevalence of depression is a combination of complex cognitive behaviour and hormonal and biochemical processes (8). In addition, depression has strong associations with traumatic life events, for example, failure in academic achievements, setback in relationships, loss of financial investments, break-up of love affairs, or the death of a loved one (9),(10). Depression makes the sufferer to withdraw from his/her personal, social and occupational activities (10),(11).

Literature search for the risk factors of depression disclose medical and social factors as the possible causes of depression. Among medical complications, heart diseases (12),(13), diabetes mellitus, Human Immune Virus (HIV) (14), stroke (15), hyperthyroidism, gynaecological cancer (16) , congested heart failure (CHF) (18), acute myocardial infarction (AMI) (19) and other cancerous conditions are quite prominent. In addition, the therapy used for viral infections (like Hepatitis B and C) has a vital role in causing symptoms of depression (14),(17). However, Stefan (2002) and Patricia (2000) have associated genetic and environmental factors and chemical imbalances in the brain as aetiological factors for depression (20),(21). Moreover, the frequent use of sedatives and sleeping pills, the use of euphoric substances like cannabis, marijuana, opiates and stimulants like cocaine, are the main causes of depression (20). Stefan (2002) provided an evidence of the high prevalence of depression among those who use alcohol frequently. Moreover, the offspring of alcoholic females are more prone to depression as compared to those of the females who avoided the use of alcohol (20).

In terms of social factors, the family, marital problems, unemployment, job dissatisfaction and the history of childhood trauma are the main causative factors for developing depression (4). Among women, stressful/forced marriage and low socio-economic status are also noted as the reasons for developing depression illness (22). These factors affect social activities, close relationships, and family activities (23),(24).

Epidemiology Of Depression In Malaysia
The World Health Organisation, in the year 2007, has provided an evidence of a high rate of depression with a lifetime risk of 7-12 % for men and 20-25 % for females in the South East Asian Region (SEAR) (27). The Ministry of Health, Malaysia MOH), is committed for the improvement of mental health (27). Epidemiological surveys in the rural areas of Malaysia have provided evidence that about 10% of the population have some sort of minor and major depressive disorders (28). The evaluation of Saroja (1997) showed that among the elderly, depression was frequent with a prevalence rate of 13%. The majority among these were with the prevalence of other medical complications like diabetes- 25%, low serum calcium levels- 16%, low albumin levels- 24% and low haemoglobin levels- 51% (29). However, among females, the prevalence rate of Post natal depression (PND) was 3.9% and among Indian females, the highest incidence of PND was 8.5% in comparison to Malay and Chinese females (30).

In spite of these facts, no current evidence is available, that reflects the prevalence and causes of depression in Malaysia. So far, no prominent effort has been cited, that has explored these issues regarding depression (31). Keeping in view the motivation, this study aims to provide the data about the prevalence of depression and the possible factors responsible for its prevalence.


Material and Methods

This was a descriptive study. Retrospective and prospective evaluations of the medical records were conducted at the psychiatry OPD, Penang, GH, from Jan 2002 till Dec 2007. Penang is one of the thirteen states and is geographically situated in northern Malaysia. The population of Penang is multicultural; Malay (42.5%), Chinese (46.5%), Indian (10.6%) and minorities (0.4%), with an estimated population of 1.5 million (32).

Patients
All the registered patients who had a confirmed diagnosis of depression at the psychiatry OPD, Penang, GH, from 1st January 2002 to 31st December 2007, were included in the study. Those with a prevalence of other psychiatry disorders in addition to depression were not included in the study. Only the cases with the prevalence of depression alone were considered. Information like socio-demographics and the stressors identified by the psychiatrist in the medical records were a part of the data collection. For additional information, all the patients on follow up were interviewed.

Ethical Consideration And Data Analysis
The study protocol was approved by the Clinical Research Centre (CRC), Penang General Hospital and Ministry of Health, Malaysia. The data was analyzed by using the statistical software, SPSS version 13®. The data with quantitative variables were expressed by mean (± SD) and range, while the qualitative variables were estimated by frequency and percentage. However, to further evaluate the association of race, gender and age group with the prevalence of depression, the Chi-square test was applied. In some cases where the cell count was less than 5, the Fischer’s exact test was applied

Results

A total of 298 patients were registered at the psychiatry OPD with a confirmed diagnosis of depression. Of these, the majority [169(56.7%)] were females. The prevalence of depression was found to be statistically significant among females (X2 =216.5, df =2, p=<0.001). In terms of ethnic groups, the majority [172(57.7%)] were Chinese (X2 =1951.5, df =5, p=<0.001. However, in terms of age majority, 121 (40.6%) were over 50 years of age (X2 =128.0, df =7, p=<0.001). Of these, 72(59.5%) were females. Details about the patients from different age groups, races and genders are described in (Table/Fig 1).

Findings revealed a gradual increase in the number of patients every year. The highest number [81(27.2%)] was registered in the year 2007, of whom 50(61.73%) were Chinese. So, overall, among the retrospective and prospective patients, depression was frequent in the Chinese. Details about the annually registered cases are described in (Table/Fig 2).

Whilst evaluating the stressors causing depression, it was revealed that medical complications and social problems were the common stressors identified during the diagnostic evaluation of the patients (Table/Fig 3). Segregation of the data in terms of gender revealed that medical complications and social problems were the frequent reasons for depression among females. A majority (thirty five of sixty two) of the patients with medical complications were females. The most prevalent medical complication was hypertension. Details about the other recorded medical complications are mentioned in (Table/Fig 4). However, among social issues, marital and family problems, followed by relationship/childhood problems and death of loved ones, were the frequent stressors among females. Financial and job related problems were the common stressors identified among males. Details about the stressors which have been identified as the possible reasons for depression are mentioned in (Table/Fig 3). On ethnic grounds, medical complications and social problems were frequent among the Chinese, as compared to other ethnic groups. Details about the ethnic classification of complications are described in [Table/Fig 5].

Discussion

Findings of this retrospective and prospective study demonstrated a high prevalence of depression among Chinese females. However, the population with age over 50 years was found to be at a risk of depression due to medical complications. The age group below 50 years was more affected by social stressors. These findings highlight the need to consider the effect of comorbid medical conditions on the mental health of the individual. Negligence in this regard will result in increased disability and costs to the community.

Hypertension and Diabetes mellitus were the most frequent medical complications reported by the patients. These findings comply with the findings of Anderson et al., 2001; Egede et al., 2002; Pies and Rogers, 2005 and Goodnick, 1995, that provided evidence of frequent depressive disorders among diabetic and hypertensive patients (33),(34),(35),(36) . A possible reason for the depressive symptoms among hypertensive patients may be due to the use of beta blockers (35). The incidence of depression along with co-morbid diabetes and hypertension was frequent among patients aged over 50 years. These findings are in compliance with the findings of Sherine et al., which reported a high prevalence of depression among elderly diabetic and hypertensive patients (37).

Other medical complications noticed singly or in combination with diabetes mellitus and hypertension were high cholesterol, gastritis, and Ischemic Heart Disease (IHD). Mehmet et al., 2007 provided solid evidence about the symptoms of depression among those reporting with gastritis and high cholesterol concurrently (38). However, depression among patients high cholesterol is still a mystery to explore. Moreover, patients with IHD are at a high risk of depression (39). One cannot assume that depression will result in IHD. However, Vikram et al., 2002 provided solid evidence about depression among patients with IHD (39).

Similarly, Shortall et al., 1996; Denburg et al., 1997 rated the population with kidney disorders as a high risk group for depression (40),(41). More specifically, those with systemic lupus nephritis reported with a high frequency of symptoms of depression (40),(41). These findings provide evidence that a variety of medical disorders and their therapies can result in depression. The main issues in dealing with co- morbid depression in this context is making an accurate diagnosis, checking the complication and interaction between depression and the medical illness and establishing an appropriate management plan that addresses both problems.

Aetiology Of Depression
Medical complications were the most common stressors which were found to result in depression These findings confirmed the evidence reported by other studies, which reported a high risk of depression among patients with various medical conditions, especially hypertension and diabetes mellitus (15),(16),(33),(36),(37).

In addition, marital, familial and relationship problems were the most common reported stressors. Detailed exploration on the basis of gender provided evidence that social issues like marital and family problems, followed by relationship/childhood problems and death of loved ones, were the frequent stressor among females. Previous findings by Sherine et al., (2003 a) confirm the association between relationship problems and familial issues as the frequently reported stressor for depression among females (42). Sherine et al., (2003a) provided evidence of a high frequency of relationship problems among females, especially with partners, parents, siblings and love ones. In addition, job related and financial problems were the frequent stressors among males (42). Patricia, 2000; and Nisar et al., 2004 have provided evidence that have proved the association of socioeconomic problems with the prevalence of depression (21),(25). Loss of loved ones was another potential stressor for depression as was revealed by studies. Depression due to loss of loved ones was reported more in females. These findings provide evidence about the sensitive and sympathetic nature of females which result in a potent emotional reaction, leading them to depressed state. Another most important stressor was the childhood problems of the patient. These problems may be due to the behaviour of parents and lack of attention and love. Child hood problems were reported more by men, but problems due to lack of attention and love was observed more among female adolescents. These findings provided a link that associated childhood problems to depression in later life (26).

Conclusion

Medical complications and social problems were the most common stressors. Overall, our findings demonstrate a high risk of depression among elderly patients with medical complications. In terms of gender, social and financial problems were potential stressors which resulted in depression. However, ethnically, in the Chinese, depression was a result of both medical complications and social problems.

Clinical Implication
At present, Malaysia is on the way to develop its mental health policy in order to control the rising incidence of the depressive disorders in the community. No current data is available that describes the aetiology of depression among the different states of Malaysia (31). These findings will be helpful for the health regulatory authorities in order to design a better mental health policy and to rectify the identified social stressor to prevent the grids of depression from further rising.

Recommendation
There is an immediate need for the social support programs to further identify the root cause of the social problems in the community. Moreover, micro credit financing can be a possible solution to resolve the financial problems in the community. In addition, it is essential to assess the quality of life of the elderly, especially those with medical complications.

References

1.
WHO, Metal Health. What is depression [online] Accessed on May 20th 2008, Available from World Wide Web WHO http://www.who.int/mental_health/management/depression/definition/en/.
2.
The Papyrus Ebers Ancient Egyptian medicine, 15 Editions Chicago: Ares Publishers 1974.
3.
Schildkraut JJ. The catecholamine hypothesis of affective disorders: a review of supporting evidence. Am J Psychiatry 1965; 122 (5): 509-22.
4.
Gregory S B. Social Causes Of Depression. Personality papers 2005 [online] Accessed on 2nd Jan 2008, Available form Word Wide Web http://www.personalityresearch.org/papers.html.
5.
Henderson AS ,Rickwood DJ. Mental health as a National Health Priority Area: focus on depression. Australian Medical Journal 2000; 172:100-101.
6.
Rauf, Z. A survey on the prevalence of depression in Asian region. Jang Magazine, Pakistan 2006; Oct 29th.
7.
WHO, Non Communicable Diseases. SEAR 2007a [online] Accessed on Feb 20th 2007 Available from World Wide Web http://www.searo.who.int/en.
8.
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