Prevalence of Depression and Anxiety and Associated Factors among Patients Visiting Orthopedic Outpatient Clinic at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia, 2017
Received Date: Mar 19, 2017 / Accepted Date: May 03, 2018 / Published Date: May 13, 2018
Introduction: Orthopedic Trauma exerts a holistic influence on survivors’ physical health including a range of mental health problems which interfere with survivors’ recovery. Psychiatric disorders and behavioral disturbances are reported to be 3-5 times more common among people with injuries and are predictor of poor outcome and ongoing disability. Therefore, assessing depression and anxiety among orthopedic trauma patients play a vital role in implementing further interventions.
Methods: Institutional based cross-sectional study was conducted at Tikur Anbessa specialized hospital from May 29-June 30, 2017. Hospital anxiety and depression scale was used to assess anxiety and depression by using face to face interview. Systematic sampling technique was used to select a total of 407 participants. Data has been analyzed using SPSS 20. Bivariate and multivariate logistic regression was done to identify associated factors. Variables with p-value <0.05 have been considered as statistically significant.
Result: Prevalence of depression and anxiety were 36.1% and 39.8% respectively. Being female (AOR=2.3595%CI (1.48,3.72)), poor social support (AOR=2.5195%CI (1.30,4.85)), developing complication (AOR=1.9195%CI (1.07,3.52)), presence of amputation (AOR=3.6495%CI (1.60,8.24)) and having pain (AOR=2.0295%CI (1.24,3.30)) for depression and being female (AOR=1.9995%CI(1.11,3.57)), having chronic medical illness (AOR=3.0795%CI(1.36,6.92)), having family history of mental illness (AOR=2.24 95%CI (1.05,5.4.91)), lower extremity injury (AOR=2.93 95%CI (1.38,6.21)) and having severe pain (AOR=2.75 95%CI (1.32,5.74)) for anxiety had significant association at p–value <0.05.
Conclusion: Prevalence of depression and anxiety were high. Being female, having poor social support, developing complication, presence of amputation and having pain for depression; and being female, having chronic medical illness, having family history of mental illness, lower extremity injury and having severe pain for anxiety were significantly associated factors. It is good if clinicians give emphasis for orthopedic patients especially for females and with chronic medical illness.
Keywords: Depression; Anxiety; Orthopedic trauma; Hospital anxiety; Depression scale
Statement of the problem
Orthopedic trauma is defined as a severe injury to part of the musculoskeletal system such as bones, joints, or ligaments. Car accidents are a common cause of Orthopedic trauma, other causes of trauma includes slips, falls, and industrial accidents . From worldwide reports Orthopedic traumatic injury accounts for 16% of the total burden of disease , this makes it the leading cause of morbidity. Most people with Orthopedic trauma injuries survive from their accident but resulted in a number of negative health outcomes . Approximately 2.8 million people experience Orthopedic injuries annually in USA .
Orthopedic Trauma exerts a holistic influence on survivors’ physical health including a range of mental health problems which interferes with survivors’ recovery. It mainly affects the psychosocial status of affected people as well as their families and careers . Psychiatric disorders and Behavioral disturbances are reported to be three to five times more common among people with injuries which are severe enough to require hospital admission . Survivors commonly develop psychiatric problems like depression and anxiety disorders . The psychological sequelae may continue long after physical injuries have been treated which leads to psychiatric illness .
The prevalence of psychological illnesses following traumatic injuries vary according to the instruments used for measurement, the timing of the assessment and types of trauma. Anxiety and Depression has been found in up to 40% and 42% of injury survivors respectively long years following injury in a study conducted at US . Another study supporting this was conducted among 363 patients after a severe Orthopedic trauma and found that 15 and 14% of them had a mental disorder .
Different studies in different countries tried to show the magnitude of depression and anxiety among orthopedics trauma victims. Among this a study from Jordan among amputated patients in their lower extremity reported the magnitude of anxiety and depression to be 37% and 20% respectively as measured by hospital anxiety and depression scale (HADS) . A cross sectional study conducted at Brazil to compare depression and anxiety in two separate samples i.e., clinical and Orthopedic trauma patients reported that magnitude of anxiety to be 35% and magnitude of depression to be 28% for the clinical sample and 44% and 33% for the Orthopedic trauma sample .
In a study done at UK to investigate the presence and rates of anxiety and depression in Orthopedic postsurgical patients using the HADS, depression and anxiety was found in 50% and 30.36% of patients respectively .
Despite the high burden of orthopedic trauma in Ethiopia, the psychiatric sequelae are almost unforeseen. This leads to an avoidable but unalleviated suffering to the survivors.
Therefore, this study described the prevalence of depression and anxiety and associated factors among orthopedic population in the study area. The results of this study serves as a source of direction for intervention by being an input in planning future services for those who develop psychological problems after sustaining orthopedic trauma.
Study setting and design
Institutional based cross sectional study was conducted from May 29-June 30, 2017 at Tikur Anbessa, specialized hospital.
The study population includes orthopedic trauma patients visiting Tikur Anbessa specialized hospital during data collection period. Those Orthopedic trauma patients who are on follow up and aged 16-65 were tried to be included in the study and those orthopedic trauma patients who were severely sick and unable to communicate were excluded from the study.
Sample size determination
The sample size was calculated by using single population proportion formula, Considering the following assumptions; prevalence p=50% because no similar study done in our country among orthopedic population, 95% confidence interval, margin of error 5%, non-response rate 10%. Therefore the final sample size was 423. A systematic sampling technique was applied to select study units at orthopedic outpatient clinic during the study period. Sampling interval (k) was determined by dividing total study population during one month data collection period by a total sample size then the starting point was randomly selected.
A structured interviewer administered questionnaire was used which has five sub sections: a socio-demographic questionnaire to assess the patients’ background information. Hospital anxiety and depression scale (HADS) was applied to determine anxiety and depression. The HADS has two subscales: the anxiety subscale (HADS-A) and the depression subscale (HADS-D). Each subscale contains seven items for a total of 14 items in the HADS . The reliability of HADS found to have cronbach’s α for the total HADS, the HADS-A and HADS-D of 0.78, 0.73 and 0.76 respectively. It has cutoff point ≥ 8 for each subscale to be positive for anxiety and depression . Substance use history was assessed by yes/no answers of respondents and is operationalized according to different literatures. Similarly chronic medical illness and family mental illness were assessed by yes/no answers of respondents. Social support was measured by the Oslo-3 social support scale. It has the sum score ranging from 3-14 . The numeric pain rating scale (NPRS) was used to measure intensity of pain. The scoring ranges from 0-10 and classified into four scales as no pain, mild pain, moderate and severe pain .
Data processing, analysis, interpretation and presentation
The completed data was entered using Epi-info 7 then it was exported to SPSS 20 version statistical software for analysis. Descriptive statistics, bivariate analysis and multivariate logistic regression were used. Bivariate analysis was used to see association between outcome and each independent variable and Variables whose p-values <0.2 were entered to multivariate logistic regression to control confounding factors. The significance was declared at p-value <0.05. Strength of association was described using adjusted odd ratio (AOR) with its respective 95% CI. Results are presented in the form of table and graphs using frequency and summary statistics such as mean and percentage to describe the study population in relation to relative variables and discussed with previous results.
Ethical clearance was obtained from both university of Gondar and Amanuel mental specialized hospital Ethical Review committee. Written Informed consent was obtained from participants aged 18 years and above. Written assent was also obtained for those who aged below 18 years from patients’ caregiver coming with them. Each respondent was informed about the objective of the study that it will contribute necessary information for policy maker and other concerned body. Anyone who was not willing to participate in the study was not forced to participate. They were also informed that all data obtained from them would kept confidentially by using code instead of any personal identifier and is meant only for the purpose of study. For the participants who were found to be positive for anxiety and depression during the study, linkage to nearby psychiatric clinic were done in order to have further assessment on their condition and it was done for a total of 18 patients.
Socio demographic characteristics
A total of 407 participants with a response rate of 96.21% were included in the study. Among this 260(63.9%) were males. The mean age of the participant’s was 37 years (SD=±13.5 yrs) ranges from 16 to 65 years, more than one fourth 109(26.8%) were in age group of 26- 35 years, 266 (65.4) were orthodox Christian religion followers, 227 (55.8%) were married, 257(63.1) reported as they have children which ranges from 1 to11, 162 (39.8%) were Amhara by ethnicity followed by Oromo accounted for 133 (32.7%) of participants (Table 1).
|No- of children||1-3 children||159||61.9|
|≥ 4 children||98||38.1|
|Educational level||Can’t read and write||53||13.0|
|college and above||95||23.3|
|Monthly income||Below poverty bench mark||189||46.4|
|Above poverty bench mark||218||53.6|
Note:*= Catholic, Adventist; **=Kefa, Siltie, Sidamo
Table 1: Distribution of orthopedic trauma patients visiting orthopedic unit of Tikur Anbessa specialized hospital, Addis Ababa, Ethiopia, 2017(n=407).
Clinical and substance related factors of participants
According to clinical factors, 99 (24.3%) of them have reported as they had comorbid medical illness among this half 49 (49.5%) of the participants were hypertension patients followed by diabetes mellitus patients which were 34 (34.3%) and 18 (18.2%) of them had other cardiac problems (Figure 1).
Regarding current and lifetime substance use, 99 (24.3%) of them used khat in their lifetime and 25 (6.1%) of them used khat within the last 3 months, more than half 222 (54.5%) of the respondents were life time alcohol users, and 69 (17.0%) were current alcohol users. 43 (10.6%) of participants used tobacco products in their lifetime and 10 (2.5%) were current tobacco product users (Figure 2).
Psychosocial and trauma related factors of participants
From the total participants 167 (41.0%) had poor social support among this 68 of them were females, 164 (40.3%) had moderate social support and among this 62 of them were females and 76 (18.7%) had good social support in which females accounted for almost half \. According to trauma related factors of respondents 133 (32.7%) had upper extremity injury, 294 (72.2%) had lower extremity injury and 16 (3.9%) had injuries from both upper and lower extremity. Road traffic accident was the cause for injury in 174 (42.8%) of study participants followed by falling accident which was responsible for Orthopedic injury in 110 (27.0%) of participants.
Regarding the type of injury 290 (71.3%) were fractures among these closed fractures accounted almost half 143 (49.3%). 67 (16.5%) developed complication and among these 60 (89.6%) developed infection. A total of 36 (8.8%) have undergone amputation, in which 13 (34.2%) have undergone amputation in their upper extremity and 25(65.8%) have undergone amputation in their lower extremity. Pain was reported by 257 (63.1%) of study participants. The mean pain intensity score of was 4.51(SD=2.34) which ranges from 1-10, among those 110(27.0%) had mild pain, 83 (20.4%) of them has moderate pain and 64(15.7%) had severe pain within the past 12 hours (Table 2).
|Upper extremity injury||Yes||133||32.7|
|Multiple limb injury||Yes||16||3.9|
|Cause for injury||Road traffic accident||174||42.8|
|Type of injury||Fracture(yes)ClosedOpenFracture and dislocation||2901439257||71.349.331.019.7|
|Dislocation and sprain(yes)||47||11.5|
|Type of complication||infection||60||89.6|
|Duration since injured||≤ 3 month||141||34.6|
Note: *=medical illness (DM, cancer, muscle TB), chill, unknown cause; **=nerve injury, medical amputation; ***=sepsis, fibrosis
Table 2: Description of trauma related factors among orthopaedic trauma patients visiting orthopedic unit of Tikur Anbessa specialized hospitals, Addis Ababa, Ethiopia, 2017(n=407).
Prevalence of depression and anxiety
My study showed that prevalence of depression was 147 (36.1%) with 95% CI (31.4, 40.3) and prevalence of anxiety was 162 (39.8%) with 95% CI (35.1, 45.2). The prevalence rate was higher among females since 77/164 (52.4%) and 87/164(53.7%) females met the screening criteria for depression and anxiety respectively is higher when compared to 70/243(47.6%) and 75/243(46.3%) of males met the screening criteria for depression and anxiety respectively in the study.
Factors associated with depression and anxiety
Bivariate analysis of factors for depression revealed that independent variables; sex, monthly income, social support, chronic medical illness, use of tobacco products in a life time, multiple site injury in the upper extremity, developing complication, presence of amputation and having pain were found to have p-value <0.2 (Table 3). On the other hand Bivariate analysis of factors for anxiety depicted that independent variables; sex, educational status, chronic medical illness, family history of mental illness, lower extremity injury, multiple site injury in the lower extremity, developing complication, presence of amputation, site of amputation and pain intensity were found to have p-value <0.2 (Table 4).
|Variables||Depression||COR(95% CI)||AOR (95 CI %)|
|Income||Below poverty bench mark||78||111||1.52(1.01,2.28)||1.30(0.83,2.06)|
|Above poverty bench mark||69||149||1||1|
|Social support||Poor||76||91||2.51(1.37,4.57)||2.51(1.30,4.85) **|
|Chronic medical illness||Yes||46||53||1.78(1.12,2.82)||1.42(0.86,2.36)|
|lifetime tobacco use||Yes||20||23||1.62(0.86,3.07)||1.67(0.82,3.42)|
|Multiple site injury upper extremity||Yes||11||10||2.02(0.84,4.88)||1.58(0.59,4.27)|
|Complication||Yes||36||31||2.40(1.41,4.08)||1.94 (1.07,3.52) *|
|Pain||Yes||104||153||1.69(1.10,2.61)||2.02 (1.24,3.30) **|
|Hosmer and Lemeshow Test|
Note:a = 0.05* P-value<0.05; ** P-value< 0.01; *** P-value<0.001
Table 3: Bivariate and multivariable analysis of factors associated with depression among orthopaedic trauma patients visiting orthopedic unit of Tikur Anbessa specialized hospitals, Addis Ababa, Ethiopia, 2017 (n=407).
|Variables||Anxiety||COR(95% CI)||AOR (95 CI %)|
|Educational status||Can’t read and write||24||29||1.49(0.75,2.94)||1.26 (0.47,3.40)|
|high school||53||56||1.70(0.97,2. 98)||1.65(0.76,3.59)|
|preparatory school||13||26||0.90(0.41,1. 97)||1.49(0.52,4.28)|
|College and above||34||61||1||1|
|Chronic medical illness||Yes||54||45||2.22(1.40,3.52)||3.07 (1.36,6.92)**|
|Family history of mental illness||yes||34||25||2.34(1.34,4.09)||2.24(1.05,4.91)*|
|Lower extremity injury||yes||130||164||2.01(1.36,3.21)||2.93(1.38,6.21)**|
|Multiple site injury lower extremity||yes||17||10||2.76(1.23,6.18)||1.90(0.70,5.18)|
|Hosmer and Lemeshow Test|
Note:a = 0.05; * P-value<0.05; ** P-value<0.01; *** P-value<0.001
Table 4: Bivariate and multivariable analysis of factors associated with anxiety among orthopaedic trauma patients visiting orthopedic unit of Tikur Anbessa specialized hospitals, Addis Ababa, Ethiopia, 2017 (n=407).
These factors were entered into multivariate logistic regression for further analysis in order to control confounding effects except site of amputation for anxiety which is found to have co linearity with lower extremity injury and dropped (Pearson correlation coefficient=1.00, p-value=0.000). As a result being female, poor social support, developing complication, presence of amputation and having pain are found to be statistically significant for depression. On the other hand being female, having chronic medical illness, having family history of mental illness, lower extremity injury and severe pain are found to be statistically significant for anxiety.
Females were 2.35 times more likely to develop depression than males (AOR=2.35,95% CI:1.48,3.72), those who had poor social support were 2.51 times more likely to develop depression as compared those who had good social support (AOR=2.51,95% CI: 1.30,4.85),the odds of developing depression among those who developed complication were1.94 times higher as compared to those who didn’t develop complication(AOR=1.94, 95% CI: 1.07, 3.52), the odds of developing depression among those who undergo amputation were 3.64 times higher as compared to those who didn’t undergo amputation(AOR=3.64, 95% CI: 1.60,8.24) and Participants who had pain within 24 hours were 2.02 times more likely to develop depression than participants who didn’t have pain (AOR= 2.02, 95% CI: 1.24, 3.30) (Table 3).
Females were 1.99 times more likely to develop anxiety than males (AOR=1.99,95% CI:1.11,3.57), those who had chronic medical illness were 3.07 times more likely to develop anxiety as compared to those who didn’t have chronic medical illness (AOR=3.07,95% CI:1.36,6.92), the odds of developing anxiety among those who had family history of mental illness were 2.24 times higher as compared to those who didn’t have family history of mental illness (AOR=2.24, 95% CI: 1.05,4.91), the odds of developing anxiety among those who had lower extremity injury were 2.90 times higher as compared to those who didn’t have lower extremity injury (AOR=2.93, 95% CI: 1.38, 6.21) and the odds of developing anxiety among those who had severe pain within the last 24 hours were 2.75 times more likely to develop anxiety when compared those who had mild pain within the last 24 hours (AOR=2.75, 95% CI: 1.32,5.74) (Table 4).
Discussion on prevalence of depression and anxiety
The study revealed that the prevalence of depression was 36.1%. This result was in line with studies conducted at US 32% among longterm limb amputation patients , Brazil 33% among orthopedic patients  and India 38% . However, the current study finding for depression was higher than the studies conducted Jordan 20% . The reason for the above difference might be due to difference in sample size which was only 54 patients in Jordan , study population who were unilateral lower limb amputated patients from both inpatient and outpatient at Jordan .
On the other hand the finding of this study on prevalence of depression was lower than a study conducted at US 42%  and another study in US 45%  in UK 50%  and in India 87.6% . This difference might be attributed to time point the studies conducted which was a long-term study after injury in US , measurement tool which was beck depression inventory (BDI) used in US , study subjects who were post-operative patients in a study conducted at UK  and indoor orthopedic patients in a study conducted at India .
The study also revealed prevalence of anxiety to be 39.8%. This result was in line with studies conducted at US 40% among 1560 traumatic brain injury patients , Jordan 37% among lower limb amputation patients  and Brazil 44% among orthopedic patients . However, the current study finding on prevalence of anxiety was higher than studies conducted at US 16%  and another study at US 34%  and UK 30.36% . This difference might be due to difference in study population which was only MVC patients at US , only lower limb amputation patients in another US study  and only post-surgical patients at UK .
The other reason for such deference might be a type of study design in which US study applied cohort study design . It might be also due to point of time a study is conducted in which a US study conducted on long-term lower limb amputation patients  and deference in sample size which was 56 in UK . On the contrary the result of current study is lower than a study conducted in US university of Florida which reported elevated level of anxiety in each participant . This difference might be due to difference in sample size since only 50 orthopedic patients were studied and difference in study design which was a cohort study .
Discussion on factors associated with depression and anxiety
Discussion on factors associated with depression: This study revealed that variables like being female, having poor social support, those who develop complication, amputation and having pain were found to be statistically significant for depression. Females were 2.35 times more likely to develop depression than males. This study was in line with a study conducted in china (AOR=2.62) . This study was supported by studies conducted in US, UK, Korea, Jordan, Hong Kong Pakistan and India [9,20,25-29].
The odds of developing depression among those who have poor social support were 2.51 times higher when compared to those who have strong social support social support. This may be due to the negative psychological effects that patients have after sustaining orthopedic trauma which lead to poor mental health, since positive social support appears to increase victims coping capacity for such events . The current study was supported by studies conducted at US and Pakistan [23,25].
Those who developed complication after orthopedic injury were 1.94 times more likely to develop depression than those who didn’t developed complication. This may be due to a reduction in functional independence and long term survival time after developing complication of orthopedic trauma injury pre or post-surgical procedures  which appears to undermine the victim’s mental wellness and increases patients’ susceptibility for mental health problems. This may also be due to immunity suppression and neurotransmitter disturbances after development of complications which are the major causes of morbidity including mental health problems, depression [32,33].
The odds of developing depression among those who undergo amputation were 3.64 times higher as compared to those who didn’t undergo amputation. This may be attributed to adjustment reactions to the new event and lose of sense of independence and having to rely on others for some of the most common everyday needs after losing of one or more limbs , because victims may come up with difficulties in carry out daily activities as well as other tasks and it affects their recovery after orthopedic injury. This may result in increased chance of physical and psychological disabilities which are major causes of emotional distress [1,34,35]. This may also be due to the fact that distortion of the patients’ body image and decreased self-esteem after amputation which sets a series of emotional, perceptual and psychological reactions . This was supported by a study conducted at Jordan .
Those who had pain within the last 24 hours were 2.02 times more likely to develop depression than those who didn’t have pain within the last 24 hours. This may be due to increased discomfort on patients which leads to increased emotional distress. It may also be due to the fact that pain is shown to cause altered synaptic connectivity at the prefrontal cortex and hippocampus , as well as altered dopamine signaling from the ventral tegmental area , these changes have been known to trigger negative symptoms of depression . This was supported by studies conducted in UK and Korea [26-28].
Factors associated with anxiety: The study also revealed that independent variables; being female, having family history of mental illness, lower extremity injury and severe pain were found to be significantly associated with anxiety. Females were 1.99 times more likely to develop anxiety than males. This was in line with a study conducted at china (AOR=2.74) . This study was supported by studies conducted in Jordan, Hong Kong, Pakistan and India [9,20,25,29].
The odds of developing anxiety among those who had chronic medical illness were 3.07 times higher when compared to those who didn’t have chronic medical illness. This may be due to distressing or disabling chronic medical illness challenges effective coping skills of survivors  and life style changes after injury which may leads to increased morbidity and immune suppression since chronic stress has a significant effect on the immune system that ultimately manifest an illness by raising catecholamine and suppressor T cells levels, which suppress the immune system .
The odds of developing anxiety among those who had family history of mental illness were 2.24 times higher when compared to those who didn’t have family history of mental illness. This may be due to the roles of genetic predisposition in making victims susceptible for anxiety when it combines with environmental factors i.e. orthopedic trauma . As far as my knowledge the significant association of having family history of mental illness with anxiety was not seen in another study among orthopedic population.
The odds of developing anxiety among those who had lower extremity injury were 2.93 times higher when compared to those who didn’t have lower extremity injury. This may be due to increased negative psychological effects that may arise from getting physical disability, catastrophic reactions for the event and life style changes after injury . This result was supported by a study conducted at Jordan  and UK .
The odds of developing anxiety among those orthopedic patients who had severe pain within 24 hours were 2.75 times higher when compared to those orthopedic patients who had mild pain within 24 hours. This may be due to increased discomfort which leads to increased distress and decreased patients’ satisfaction and delayed ambulation which leads to increased morbidity [45-47]. This was supported by a study conducted in UK and Korea [26,28].
Conclusion and Recommendation
In the current study the prevalence of depression and anxiety were high. Being Female, having poor social support, developing complication, presence of amputation and having pain were significantly associated with depression. On the other hand being Female, having chronic medical illness, having family history of mental illness, lower extremity injury and having severe pain within the last 24 hours were significantly associated with anxiety. It is good if clinicians working at orthopedic clinics give emphasis for patients’ psychological state during evaluating especially for females, those having comorbid medical illness, develop complication, patients who undergo amputation and those with severe pain. It is also good if other researchers conduct prospective cohort study to investigate temporal relationship between factors such as comorbid medical illness and amputation, and depression and anxiety.
First of all, we would like to express our thanks to University of Gondar College of medicine and health science department of psychiatry and Amanuel mental specialized hospital for giving us the chance to develop this thesis and funding study. We would like to extend our deepest thankfulness for Tikur Anbessa specialized hospital management staffs and orthopedic clinic nurses for their respect and cooperation during data collection period. We would also like to thank study participants.
MS participated in the conception and design of the study, wrote the proposal, participated in data collection, analysis and write up of this manuscript. Niguse Yigizaw, Tolesa Fanta, Dawit Assefa and Enguday Tirfeneh participated in the design of the study, wrote the proposal, analysis and write up and edition of this manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interest.
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Citation: Srahbzu M, Yigizaw N, Fanta T, Assefa D, Tirfeneh E (2018) Prevalence of Depression and Anxiety and Associated Factors among Patients Visiting Orthopedic Outpatient Clinic at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia, 2017. J Psychiatry 21: 450. DOI: 10.4172/2378-5756.1000450
Copyright: © 2018 Srahbzu M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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