A high prevalence of depressive symptoms was observed among the healthy participants, and depressive symptoms increased with age. Self-employed women or women engaged as students or apprentices had reduced odds of reporting depressive symptoms compared to unemployed women. Being an orthodox Christian appeared to offer protection against depressive symptoms. Despite the strong association between age, employment, and depressive symptoms, we caution against the assumption of causality. Proving causality in cross-sectional studies is statistically and empirically difficult.
We found a relatively higher prevalence of depressive symptoms in our study than has previously been reported [6, 11, 16,17,18,19]. The only exception we are aware of is the 41.1% figure reported for Vietnam [18]. One reason for this may have been the relatively few items used in our assessment of depressive symptoms. We distinguished depressive symptoms from clinical depression that would require a stricter criterion, as specified in the DSM 5 or ICD-10. Even so, the assessment of depressed mood, sleep disturbance, and worry or anxiety are prominent symptoms of depression and are usually adversely affected during depression. Therefore, the proportion of people who might show clinically relevant signs of depression and yet would not consider the symptoms serious enough to seek treatment is interesting. These early signs of depression may be due to high levels of stress associated with the hassles of urban living. Much evidence exists showing strong links between poor mental health and stress or urban living [20, 21]. Other studies have shown an increase in nuclear families in urban areas, which in turn is associated with increased violence among women and the mental health of poor women [19]. In other words, the social safety net provided by the extended family in less urban areas is either diminished or removed, exposing vulnerable individuals to high stress levels, possibly due to challenging economic circumstances.
Our results support earlier studies on the association between age and depression. For example, Deyessa and colleagues [11] showed that the odds of experiencing depression increase with age. Compared to younger women, older individuals have more anxieties stemming from multiple sources: marriage, children, stable employment, and income. Older unmarried women have more worries about marriage and childbirth, motivated by societal pressures on marriage, [22] particularly in Africa where marriage and motherhood are expected of every woman.
In the crude analysis—compared to women who never married—unmarried women (divorced, separated, or widowed) had significantly higher odds of reporting depressive symptoms. This finding supports earlier reports by others [11]. Arguably, these life changes, in the absence of adequate social support, will present substantial stress that can induce depression.
Contrary to what has been reported previously, we did not find an association between socioeconomic status and depression, despite adequate global reporting of this effect [4, 5, 23]. For example, a large scale longitudinal study in Belgium reported that increases in financial strain, poverty, and the end of cohabitation were associated with increased depressive symptoms [23]. We found some of these in our study, but our measure of socioeconomic status was based on the respective locality or census enumeration areas within which we selected our respondents. A lack of variability in the enumeration areas likely limited the different characteristics that might contribute to socioeconomic status. In Nigeria, a higher prevalence has been reported among rural dwelling people than among urban inhabitants [24]. While we did not compare between rural and urban populations, rural societies are associated with lower education and income, both of which are indicators of lower socioeconomic status. The measure of socioeconomic status is not consistent in many instances and that should be noted in future research.
We found a limited effect of ethnicity and religion on depressive symptoms; that is, the effect was reported only for specific groups, such as Akans and non–orthodox Christians. Compared to indigenous Ga women, the reduced odds of depression observed among women of Akan extraction in both the crude and the adjusted model are interesting and present an interesting subgroup worth exploring in future research.
The major finding of this study is the realization that more self-reported depressive symptoms, or mild forms of depression, might exist in supposedly healthy populations than has previously been reported. This has important implications for public health policy. In routine examinations, we should begin including an assessment of mood disorders among selected groups, especially among older adults or individuals under economic strain. The usefulness of early detection of mental health problems cannot be overemphasized. With this in mind, we can begin to institute referrals and interventions following early detection and diagnosis of depression. Counselling and psychological services are limited and expensive globally. In many countries, particularly LMICs, they are not covered by health insurance schemes, thereby making them inaccessible. When counselling and psychological services are placed in the public health domain, provision of care is easily accessible.
Limitations
This study is not without limitations.
First, it is a cross-sectional study and therefore, as we have stated earlier, is limited in making any causal associations between the predictors and prevalence of depressive symptoms. One issue that should be clarified is the definition of depression as distinctly different from clinical depression. Measurement of clinical depression is much more stringent and usually follows criteria determined by DSM 5 or ICD 10. Our assessment of depression involved a self-reported assessment of the degree of disturbance in three symptoms usually associated with depression within 1 month. Most depression inventories are more detailed. We also acknowledge that self-reported measures are not as robust as objective assessments of behaviour. Self-reported data also have issues with recall bias. Diseases associated with mental health are stigmatized in Ghana; therefore, subjects may be tempted to hide their depression status.
Second, socioeconomic status was measured based on residence, an assumption supported by data from the Ghana Statistical Service enumeration data. We have reported previously that this is limited. Despite this, there is very little unanimity in the measurement of socioeconomic status across studies.