PREVALENCE, PATTERN, AND CORRELATES OF

DEPRESSION AMONG DRUG-SUSCEPTIBLE

TUBERCULOSIS PATIENT ENROLLEES IN

OGBOMOSO, OYO STATE

A RESEARCH PROPOSAL DELIVERED BY GROUP C IN

PARTIAL FULFILMENT OF THE REQUIREMENTS OF THE
AWARD OF BACHELOR OF MEDICINE; BACHELOR OF
SURGERY (MB; BS) DEGREE BY LADOKE AKINTOLA
UNIVERSITY OF TECHNOLOGY

SUPERVISORS:
PROF. PARAKOYI D.B
DR OLAREWAJU S.O
GROUP MEMBERS
1. KAYODE AYOMIDE TIMILEHIN 160010
2. AYINMODU JANET OLUWASEYI 160061
3. ABDULSALAM ZAINAB ADEDAMOLA 160087
4. OYEDEJI OLUWATOBA JEREMIAH 160390
5. OLANIYAN DOYIN VICTORIA 162730
6. OLADEJI OLUSHINA OLOLADE 162012
7. ODEDELE JOHN TEMITAYO 162649

2
ATTESTATION

I attest that I have read and approved this proposal for submission to the Ethical Review

Committee, LAUTECH Teaching Hospital, Ogbomoso.

Dr Olanrewaju, S.O.

Project Supervisor

3
 TABLE OF CONTENTS

CHAPTER ONE: INTRODUCTION

1.1 BACKGROUND INFORMATION………………………………………………………………………. 4

1.2 STATEMENT OF PROBLEM……………………………………………………………………………. 5

1.3 JUSTIFICATION OF STUDY……………………………………………………………………………. 6

1.4 RESEARCH QUESTIONS………………………………………………………………………………… 6

1.5 RESEARCH OBJECTIVES………………………………………………………………………………. 7

1.6 HYPOTHESIS TESTING………………………………………………………………………………….... 8

CHAPTER TWO: LITERATURE REVIEW

2.1 OVERVIEW OF TUBERCULOSIS………………………………………………………………………... 8

2.2 BURDEN OF TUBERCULOSIS…………………………………………………………………………... 8

2.3 STRATEGY TO CONTROL TUBERCULOSIS…………………………………………………………… 9

2.3.1 END TB STRATEGY………………………………………………………………………………… 10

2.4 DEPRESSION AMONG TUBERCULOSIS PATIENTS…………………………………………………... 11

2.5 CONCEPTUAL FRAMEWORK……………………………………………………………………………. 12

CHAPTER THREE

3.1 STUDY AREA……………………………………………………………………………………………… 13

3.2 STUDY DESIGN…………………………………………………………………………………………… 13

3.3 STUDY POPULATION……………………………………………………………………………………. 13

3.4 SAMPLE SIZE CALCULATION…………………………………………………………………………. 14

3.5 STUDY TECHNIQUE……………………………………………………………………………………. 14

3.6 STUDY INSTRUMENT………………………………………………………………………………….. 14

3.7 PRETESTING OF RESEARCH INSTRUMENT………………………………………………………… 15

3.8 DATA COLLECTION AND MANAGEMENT…………………………………………………………... 15

3.8.1 MEASUREMENT OF OUTCOME VARIABLES…………………………………………………. 15

3.9 ETHICAL CONSIDERATIONS…………………………………………………………………………. 15

QUESTIONNAIRE 16

PATIENT HEALTH QUESTIONNAIRE 18

REFERENCES 20

4
 CHAPTER ONE: INTRODUCTION

1.1 BACKGROUND INFORMATION

Tuberculosis (TB), an infectious disease caused by Mycobacterium tuberculosis is still one of the

leading public health problems despite advances in the effort to reduce its incidence, morbidity,
1–5
and mortality. In 2021, about 10.6 million people were reported by the World Health

Organisation (WHO) to be infected with Tuberculosis,6 with an estimated 23% of the global burden

and 33% of the global TB death in Africa.7 Nigeria ranks first in Africa, one of the 10 countries

with the highest number of missing TB cases, the sixth in the world, contributing to almost 4.6%

of the global burden. It is also responsible for a high triple burden of TB, Drug-resistant TB, and

HIV-associated TB.8

The prevalence of tuberculosis has been linked to a reduction in the immune and nutritional status

associated with adverse conditions including overcrowding, poverty, and marginal living

conditions, especially in developing countries including Nigeria.3 The WHO in their response to

combat the disease introduced the Directly Observed Short Treatment Course (DOTS) in 19959,

the Stop TB strategy in 2006, and the End TB strategy in 201410 are the currently available forms

of management to control and cure TB in Nigeria. The treatment of TB in Nigeria is free and based

on the National Tuberculosis and Leprosy Treatment Guidelines.11 This approach has greatly

improved the management of TB and has changed the focus from the prevention of mortality to

the prevention of morbidity.

However, due to the infectious nature of the disease, a patient with Tuberculosis is thought to be

dangerous and therefore avoided by society, leading to social isolation, stigmatization, and

rejection. Other factors including the loss of income, side effects of the medications, and the need

5
to keep up with review appointments gradually tilt him towards psychological disorders such as
3–5
depression. Depression is a mental state characterized by loss of interest, feelings of guilt,

disturbed sleep or appetite, loss of self-worth, and usually suicidal thoughts.1,2 Chronic pain,

frequent hospital admissions, and dependency on the hospital found in patients with Tuberculosis

have been reported to be associated with depression.5,12

1.2 STATEMENT OF PROBLEM

It is estimated that about 2 billion people are infected with tuberculosis worldwide. Every year

about 10 million people get tuberculosis. According to WHO Tuberculosis is the 13th leading cause

of death worldwide and affecting about 10.6 million people worldwide in 2021 alone.13

In 2018, about 1.5 million people died from the disease and the majority of the new cases recorded

were in 8 countries which include: India, China, Indonesia, Philippines, Nigeria, Bangladesh, and

South Africa in the order of incidence. The prevalence of TB in Nigeria is high ranking 6th among

the 30 TB high-burden countries in the world.6 Tuberculosis mostly affects adults but all age

groups are at risk. About 80% of deaths occur in LMIC.6

Depression is a common mental disorder. About 5% of adults suffer from depression globally

(WHO 2023). Depression is a major cause of suicide with more than 700,000 people dying due to

suicide every year.14 The majority of patients with Tuberculosis suffer from depression which

could be due to the long-term nature of the treatment and also stigmatization from society. Also,

studies have shown that the prevalence of depression correlated with the severity and duration of

tuberculosis.15

Depression that accompanies the disease is often due to the nature of the infection, side effects of

medications, and other social determinants of health. Several studies have shown a higher

6
prevalence of depression among patients with Tuberculosis as compared to the general population.

A study done in Nigeria by Ige O.M and Lasebikan O.A showed a prevalence of about 45. 5%.12

1.3 JUSTIFICATION OF STUDY

Tuberculosis is associated with psychiatric comorbidity particularly depression which has been

recognized as a cause of poor compliance to medication and an increase in the risk of mortality

and morbidity from the disease. 9 Despite tuberculosis being a curable infection, its impact on the

quality of life of the patients has increased over the years and depression is a major contributor to

this. This might be a result of much attention being placed on the curative and preventive aspects

of the disease. However, little or no attention is placed on the recognition of early signs of

depression and finding ways to help the patients.

When TB and depression coexist, patients tend to suffer in silence and when accompanied by poor

compliance to medication mortality rate also increases. Paying attention to some of the

psychosocial issues that patients under treatment for tuberculosis experience may optimize

adherence and increase the success of treatment. It is therefore important to find out the prevalence

and pattern of depression among drug-susceptible TB patients to improve drug compliance,

improve treatment outcomes and thereby reduce morbidity and mortality from the disease.

1.4 RESEARCH QUESTIONS

a. What is the prevalence of depression among drug-susceptible tuberculosis cases in

Ogbomoso Local Government Areas?

b. What is the pattern of depression among drug-susceptible tuberculosis cases in Ogbomoso

Local Government Areas?

7
 c. What are the factors associated with depression among the Drug susceptible Tuberculosis

patient enrollees in Ogbomoso?

1.5 RESEARCH OBJECTIVES

1.5.1 General Objective

To determine the prevalence, Pattern, and correlates of Depression among drug-susceptible

tuberculosis patient enrollees in Ogbomoso, Oyo-State

1.5.2 Specific Objectives

a. To determine the prevalence of depression among drug susceptible patients with

tuberculosis

b. To assess the patterns of depression among drug-susceptible TB patients

c. To determine the factors responsible for depression among patients with tuberculosis in

Ogbomoso

1.6 HYPOTHESIS TESTING

H0= Depression is not associated with socioeconomic status among Drug-susceptible Tuberculosis

patient enrollees in Ogbomoso, Oyo state.

Ha= Depression is associated with socioeconomic status among Drug-susceptible Tuberculosis

patient enrollees in Ogbomoso, Oyo state.

H0= Depression is not associated with socio-demographic status among Drug-susceptible

Tuberculosis patient enrollees in Ogbomoso, Oyo state.

Ha= Depression is associated with socio-demographic status among Drug-susceptible Tuberculosis

patient enrollees in Ogbomoso, Oyo state.

8
H0= Depression is not associated with comorbid conditions such as HIV among Drug susceptible

Tuberculosis patient enrollees in Ogbomoso, Oyo state.

Ha= Depression is associated with comorbid conditions such as HIV among drug-p

susceptible Tuberculosis patient enrollees in Ogbomoso, Oyo state.

9
 CHAPTER TWO: LITERATURE REVIEW

2.1 OVERVIEW OF TUBERCULOSIS

Tuberculosis is an infectious disease caused by Mycobacterium tuberculosis which can primarily

affect the lung (pulmonary) or other organs such as the adrenal, genitourinary, and intestines

(extrapulmonary). It accounts for 2% of the global health burden and is the leading cause of

morbidity and mortality by infectious diseases Nigeria is the second highest TB burden in Africa

and fifth among the highest TB burden countries in the world.16

Tuberculosis is transmitted by inhalation of aerosol containing the active bacilli. However,

following inhalation, it may fail to become an infection, clear up or cause an infection but

asymptomatic, or become a progressive Tuberculosis disease. It initiates both the innate and

adaptive response and the outcome of the tuberculosis depends on the response. Tuberculosis, upon

reaching the macrophage may be eradicated or enter dormancy forming granulomas. It remains

viable within the granuloma for years and reactivation may occur when the immune system is

compromised.12

2.2 BURDEN OF TB

Tuberculosis is the most common cause of death from a single infectious agent globally and eight

countries including Nigeria, South Africa, Bangladesh, Philippines, China, and Indonesia make up

two-thirds of the global burden of TB.17 It has been estimated that the slow reduction in the global

incidence rate of TB by 1.6% per year is not up to the goal of WHO to reach about 4-5 % per year

and at this rate will be impossible to achieve the Sustainable Development Goal (SDG) goal by

2030 which also includes the goal of eradicating TB epidemics and reducing the number of deaths

by 80% in number by 2023.18

10
In Africa, TB prevalence accounts for 25% of the world's cases, and its co-infection with HIV by

15%. In 2016, the West African countries, Sierra Leone, Nigeria, and Liberia made it to make it to

the top 30 countries with the highest TB burden. The disease prevalence is still numerous in Africa

despite the advances in eradicating TB globally and there is a limit to manpower in terms of

personnel, funds, and medical supplies. Nigeria was first in Africa and the sixth among thirty

countries in the world of highly burdened TB countries. It is also among the two-third burdened

countries in the world making up 4.4%. This disease has a negative implication on the growth and

development of the country as the most productive age group has the highest prevalence.19,20

It is estimated that 30 people die of TB every hour in Nigeria and the states with the highest

boarding are Kaduna, Lagos, Kano, Oyo, Benue, Rivers, and Akwa Ibom states. Nigeria has started

the end TB strategy which is determined to reduce the prevalence of TB by 50% and its mortality

by 70%. 21 Also, the burden of disease in many countries has shifted from communicable to non-

communicable diseases. With their epidemiological transition, these countries with reduced burden

can help other countries with insights on how they control it and countries with high burden should

investigate major causes of the prevalence and incidence of the disease.19

2.3 STRATEGIES TO CONTROL TB

The National Tuberculosis and Leprosy Control Program (NTBLCP) helps the government in TB

control aimed at improving case detection, treatment, and success rate. Also, the implementation

of the WHO-recommended Directly Observed Treatment Strategy (DOTS) ensures treatment

adherence, reducing the emergence of drug resistance and improving treatment outcomes.21

Nigeria initially started with the Directly Observed Treatment Short course (DOTS) which

involves the commitment of the government, case detection, standardized recording and reporting

11
system which led to an increase in the ability to notify new TB cases. The limitations of the DOTS

center strategy led to the adoption of the STOP TB strategy which includes DOTS expansion and

enhancement which addresses TB-HIV incidents, multi-drug resistant TB (MDR-TB), and the

needs of the population that are vulnerable to tuberculosis.22 To attain the Sustainable

Developmental Goals (SDGs), the END TB strategy was adopted which centralizes on both policy

and supporting system.22

2.3.1 END TB STRATEGY

The World Health Assembly (WHA) adopted this strategy in 2014 to end the global burden of TB

epidemics and also to achieve the goals of sustainable developmental goal which aimed to reduce

TB incidence by 80%, TB deaths by 90%, and to eliminate catastrophic costs for TB affected

households by 2030.22

It is built on three strategic pillars which work with four principles;10

1. Integrated patient-centred care and prevention: It puts people with TB at the heart of the

service centre by focusing on early detection, treatment, and prevention for all TB patients

including children, and also aims to ensure that all TB patients not only have equity but

also unhindered access to affordable services, and making sure they also engage in their

care.

2. Bold policy and supporting system: It involves the intense involvement of government,

communities, and private stakeholders, strengthening health and social sector policies and

systems to prevent and end TB supporting implementation of universal health coverage,

and social protection, and strengthening regulatory frameworks. It also addresses the social

12
 determinants of TB and tackles TB among vulnerable groups of people such as the very

poor, people living with HIV, migrants, refugees, and prison.

3. Intense research and innovation: This is focused on pursuing operational research for the

design, scaling-up of innovations, and implementation, calling for an urgent boost in

research investments so that new tools are developed and widely accessible in the next

decade.

These pillars focused on bringing interventions together to ensure patients with TB have equity in

accessing high-quality diagnosis treatment care. Also, the principles on which these pillars work

include;

1. Government stewardship and accountability with monitoring and evaluation

2. Building cultures with civil society and community

3. Protecting and promoting human rights ethics

4. Adoption of strategy and targets at the country level with global collaboration

However, the success of this strategy will depend on countries implementing the key principles

and pillars of this strategy. When implemented, we help in curbing the challenge of finding missing

TB patients and the multi-drug resistance TB pandemic.10,22

2.4 DEPRESSION AMONG TB PATIENTS

Depression is a common mental health problem affecting millions of people globally, more than

300 million people posing a major significant challenge for public health in the country and

globally.23 The prevalence of depression among people with TB is between 40% to 70% which

shows a high prevalence in Pakistan, 80%, a comparable proportion in Nigeria, 40.45%, and

Ethiopia, 59.9% with a lower prevalence in India the prevalence of depression.24 The prevalence

13
of depression among TB patients in southwest Nigeria was found to be 31.5% by Alobu et al 24,

45.5 % by Ige et al.12 Similarly, a systematic review and meta-analysis by Pachi et al. in 2019,

including studies from multiple countries, reported that the overall prevalence of depression among

TB patients was 36.5%, these high statistics suggest for urgent needs of support and intervening

program for an individual with TB.15

Depression, however, can significantly impact the treatment of TB patients, as seen in a study done

to assess the impact of comorbid depression on TB treatment outcomes in South-Western Nigeria,

TB patients with coexisting depression were reported more likely to experience treatment non-

adherence.25

Many factors contributing to the global development of depression among TB cases include social
26
insulation, fiscal difficulties, and stigmatisation associated with TB detection. Other factors

include age, expansive pathology, long illness duration, and unattached status as risk factors for

depression in cases.12 The combination of these factors can complicate the internal health burden

of TB cases, hindering their overall well-being and recovery.

Access to internal health care services is a critical concern for TB cases in Nigeria as the significant

lack of internal health services in the tuberculosis treatment centres, poses a considerable challenge

for furnishing acceptable internal health support to TB cases, also, the majority of TB cases with

depression in India didn't admit acceptable internal health care.27, and a methodical review reported

significant differences in access to internal health services among TB cases, especially in low- and

middle-income countries.28 These findings emphasize the critical need to ameliorate internal

healthcare structure and integrate internal health services within TB treatment programs on a

global scale.

14
Efforts to address depression among TB patients globally should be multi-faceted and involve

collaboration between healthcare providers, policymakers, and communities. The government

should consider integrating mental health services into TB care to improve patient outcomes. 29,

and the implementation of psychosocial interventions to reduce depression and improve treatment

adherence among TB patients. These proposed interventions highlight the need for comprehensive

and context-specific strategies to address depression among TB patients across different regions

worldwide. Additionally, implementing mental health awareness campaigns and providing training

for healthcare professionals on mental health issues can destigmatize depression and encourage

patients to seek help.

15
2.5 CONCEPTUAL FRAMEWORK

16
 CHAPTER THREE: METHODS AND MATERIALS

3.1 STUDY AREA

This study will be carried out in Ogbomoso, Southwestern Nigeria. It was established in the middle

of the eighteenth century and is a city in Oyo State, southwest Nigeria. As of 1991, its population

was at 645,000. One of Nigeria's largest metropolitan hubs, the city is thought to be. Yoruba people

make up the majority of the population. Some of the region's notable crops include yams, cassava,

maize, and tobacco.30

There are 5 LGAs in Ogbomoso town namely Oriire, Ogbomoso South, Ogbomoso North, Ogo-

Oluwa, and Surulere. Tuberculosis control in each LGA is under the purview of the Tuberculosis

and leprosy control supervisor who is working under the Primary Health Care Development

Agency. He mentors and supervises clinical and diagnostic activities across DOTS and diagnostic

centres, supplies recording and reporting materials, and laboratory reagents, and collates data on

activities conducted within each quarter for submission, reporting, and presentation during State

quarterly review meetings.

3.2 STUDY DESIGN

This study will be a cross-sectional hospital-based survey involving quantitative methods of data

collection. The study will be conducted across all the Direct Observed Therapy (DOT) centres in

all the local governments in Ogbomoso. The DOT centres owned by both state and local

governments will be used for the study.

17
Basic details including the patient's age, sex, address, tuberculosis type, and treatment outcome

will be included in the registration paperwork that will be examined.30

3.3 STUDY POPULATION

All patients with all forms of TB attend the DOT centres in all 5 local governments in Ogbomoso.

Inclusion criteria

The main inclusion criteria are TB patients, aged 18 years and above, who have been on drugs for

two months and there's proof of drug susceptibility, and who are mentally capable of providing

consent.

Exclusion criteria

• Newly diagnosed and unregistered pulmonary tuberculosis patients will not be considered.

• Pregnant women with pulmonary TB.

• Severely ill or debilitated patients will not be included.

• Patients with extrapulmonary TB will not be included.

• Patients who cannot give consent will not be included.

3.4 SAMPLE SIZE ESTIMATION

Leslie Fischer's formula is used for cross-sectional descriptive study:

n= z²pq /d²

Where:

Z is the standard normal deviate at a 95% confidence interval which is 1.96

18
The proportion for the prevalence of depression among DS TB patients in the previous study was

27% (0.27).9

q is 1-p = 1- 0.27= 0.73

d is the error margin which is 5% (0.05).

n = 303 participants.

Add 10% non-response, a total of 333 questionnaires will be administered during fieldwork.

3.5 SAMPLING TECHNIQUE

A multistage sampling technique will be used.

First stage: From the list of urban and rural local government areas in Oyo state, 2 local

governments each will be chosen by simple random sampling making a total of 4 local

governments.

Second stage: The list of all registered DOT centres will be collected from the local government

headquarters/ council. Four DOT centres will be selected from both rural and urban local

governments respectively by simple random sampling by balloting technique, making a total of 8

DOT centres.

Third Stage: Using proportional allocation based on sample size, clients will be selected from each

DOT centre using a systematic sampling approach until we recruit enough sample allocated

percenter

3.6 STUDY INSTRUMENTS

Quantitative method using Semi-structured questionnaire.

19
A semi-structured questionnaire will be used as the survey instrument. This will be designed to

seek information about the prevalence, and pattern of depression among drug-susceptible

tuberculosis enrollees in Ogbomoso. The research assistants will be the students in the community

medicine project group. The questionnaire to be used has the following sections:

Section A: Background status.

Section B: Lifestyle and other co-morbidities conditions among respondents.

Section C: Assessment of Depression among respondents.

3.6.1 MEASUREMENT OF OUTCOME VARIABLES

The question about lifestyle and other co-morbidities will be scored. For questions whose

responses will be either yes or no (or correct or incorrect), a correct answer will be scored 1 and a

wrong answer will be scored 0. For questions with three responses, (“Yes”, “No” and “I don’t

know”), the correct response will score 2, “I don’t know” or “no idea” will score 1 while the wrong

response will be scored 0.

For questions on assessment of depression among respondents, whose responses are (Not at all,

several days, more than half the days, every day) in the last two weeks, a correct answer will be

scored 3, more than half the days - 2, Several days - 1, Not at all - 0).

3.7 PRETESTING OF RESEARCH INSTRUMENT

The validity of the research instrument will be tested by pre-testing the questionnaires among TB

patients in one of the DOT centres not part of the sample population. This will help to know

whether the questionnaire measures what it is intended to measure and whether the language and

organization are appropriate to address the purpose and goals of the study.

20
3.8 DATA COLLECTION AND MANAGEMENT

Questionnaires will be sorted out to check for errors and omissions at the end of the collection of

data. Thereafter, data will be entered into the computer and analyzed using Statistical Package for

Social Sciences (SPSS) version 20. Frequency distribution tables, charts, and graphs will be

generated from variables while cross-tabulation and test statistics will be done where applicable.

Chi-square will be used to compare rates, ratios and proportions while the Fisher exact test will be

used when cells have expected values less than 5. T-test will be used to determine the association

between the continuous variables. The level of significance will be set with a p-value less than

0.05.

3.7 ETHICAL CONSIDERATIONS

Ethical approval for the study will be obtained from the LAUTECH Teaching Hospital Ethical

Review Committee and permission to carry out the study will be obtained.

Right of decline/withdraw from study. Respondents were told that participation is voluntary and

they will not suffer any consequences if they choose not to participate.

Confidentiality of data: All information gathered will be kept confidential. Participants will be

identified using serial numbers.

21
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26
 QUESTIONNAIRE

ASSESSMENT OF DEPRESSION, PATTERNS AND ITS CORRELATES AMONG

DRUG SUSCEPTIBLE TUBERCULOSIS PATIENTS IN OGBOMOSO, OYO STATE.

Hello, we are final-year medical students from Ladoke Akintola University of Technology,

Ogbomoso. We are conducting a study on the PREVALENCE, PATTERN, AND CORRELATES

OF DEPRESSION AMONG DRUG SUSCEPTIBLE TUBERCULOSIS PATIENT ENROLLEES

IN OGBOMOSO, OYO STATE.

This questionnaire will assess you for depression and we can assure you that any information

provided here will be kept confidential. Your data will be used anonymously and the summary of

the results will be published in a medical journal.

Kindly note that participation in this study is voluntary and will not be used against you in any

way.

If you CONSENT to give your information to be used in this study, kindly append your signature

below.

Signature: …………………

LGA TB No: …………………

SECTION A: Background Status

1. Age (as at last birthday): …….

2. Sex: a) Male ☐ b) Female ☐

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3. Religion: a) Christian ☐ b) Muslim ☐ c) Traditional ☐ d) Others ☐

4. Marital Status: a) Single ☐ b) Married ☐ c) Widow ☐ d) Widower ☐

5. Ethnicity: a) Yoruba ☐ b) Igbo ☐ c) Hausa ☐ d) Others; specify………...

6. Level of education: a) No education ☐ b) Primary education ☐ c) Secondary ☐ d) tertiary ☐

7. Occupational status: a) Employed ☐ b) Unemployed ☐ c) Student ☐

8. Average income per month a) Less than ₦18 000 ☐ b) Above ₦18 000 ☐

6. What regimen of treatment at you on? a) Regimen 1 ☐ b) Regimen 2 ☐

7. What phase of treatment are you? a) Intensive phase ☐ b) Continuation phase ☐

SECTION B: Lifestyle and other co-morbid conditions among respondents

8. Do you drink alcohol a) Yes ☐ b) No ☐

9. If yes, how many bottles per day? ….…

10. Do you smoke a) Yes ☐ b) No ☐

11. If yes, how many sticks per day? ……

12. Body Mass Index

Weight: kg

Height: m

13. Are you living with diabetes? a) Yes ☐ b) No ☐ c) Unknown ☐

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14. Are you living with hypertension? a) Yes ☐ b) No ☐ c) Unknown ☐

15. HIV status: a) HIV positive ☐ b) HIV negative ☐ (Confirm from patient treatment card)

16. Any previous history of mental illness(es)? a) Yes ☐ b) No ☐

17. Any family history of mental illness(es)? a) Yes ☐ b) No ☐

SECTION C: Assessment of Depression among Respondents

Please, answer the following with only one of 'not at all', 'several days', 'more than half the days'

or 'every day'. Kindly tick the appropriate box.

NOTE: The timeframe for all questions is the past 2 weeks.

Not At All Several Days More Than Half Everyday

the Days
18. Have you
had little interest
or pleasure in
doing things?
19. Have you
had a poor
appetite or been
overeating?
20. Have you
been feeling
down, depressed,
or hopeless?
21. Have you
had trouble
falling or staying
asleep, or been
sleeping too
much?

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22. Have you
been feeling
tired or having
little energy?
23. Have you
been feeling bad
about yourself -
or that you are a
failure or have
let yourself or
your family
down?

24. Have you

been moving or
speaking so
slowly that other
people could
have noticed or
been restless?

25. Have you

had trouble
concentrating on
things, such as
reading the
newspaper or
watching
television?

26. Have you

had thoughts that
you would be
better off dead,
or of hurting
yourself in some
way?

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 SE C T I ON C
P AT IE N T HE A L T H QUESTIONNAIRE (PHQ-9)
#:
NAME: DATE:

Over the last 2 weeks, how often have you been

bothered by any of the following problems?
More than Nearly
(use " ⁿ " to indicate your answer) Not at all Several
half the every day
days
days

1. Little interest or pleasure in doing things 0 1 2 3

0 1 2 3
2. Feeling down, depressed, or hopeless

0 1 2 3
3. Trouble falling or staying asleep, or sleeping too much

4. Feeling tired or having little energy 0 1 2 3

0 1 2 3
5. Poor appetite or overeating

6. Feeling bad about yourself or that you are a failure or

0 1 2 3
have let yourself or your family down

7. Trouble concentrating on things, such as reading the

0 1 2 3
newspaper or watching television

8. Moving or speaking so slowly that other people could

have noticed. Or the opposite being so figety or
0 1 2 3
restless that you have been moving around a lot more
than usual

9. Thoughts that you would be better off dead, or of

0 1 2 3
hurting yourself

add columns + +

(Healthcare professional: For interpretation of TOTAL, TOTAL:

please refer to accompanying scoring card).

10. If you checked off any problems, how difficult Not difficult at all
have these problems made it for you to do Somewhat difficult 31
your work, take care of things at home, or get
Very difficult
along with other people?
Extremely difficult
 PHQ-9 Patient Depression Questionnaire
For initial diagnosis:

1. Patient completes PHQ-9 Quick Depression Assessment.

2. If there are at least 4 3s in the shaded section (including Questions #1 and #2), consider a
depressive disorder. Add score to determine severity.

Consider Major Depressive Disorder

- if there are at least 5 3s in the shaded section (one of which corresponds to Question #1 or #2)

Consider Other Depressive Disorder

- if there are 2-4 3s in the shaded section (one of which corresponds to Question #1 or #2)

Note: Since the questionnaire relies on patient self-report, all responses should be verified by the
clinician, and a definitive diagnosis is made on clinical grounds taking into account how well the
patient understood the questionnaire, as well as other relevant information from the patient.
Diagnoses of Major Depressive Disorder or Other Depressive Disorder also require impairment of
social, occupational, or other important areas of functioning (Question #10) and ruling out normal
bereavement, a history of a Manic Episode (Bipolar Disorder), and a physical disorder, medication, or
other drug as the biological cause of the depressive symptoms.

To monitor severity over time for newly diagnosed patients or patients in current treatment
for depression:

1. Patients may complete questionnaires at baseline and at regular intervals (eg, every 2
weeks) at home and bring them in at their next appointment for scoring or they may
complete the questionnaire during each scheduled appointment.
2. Add up 3s by column. For every 3: Several days = 1 More than half the days = 2 Nearly every day
= 3 3. Add together column scores to get a TOTAL score.
4. Refer to the accompanying PHQ-9 Scoring Box to interpret the TOTAL score.
5. Results may be included in patient files to assist you in setting up a treatment goal, determining
degree of response, as well as guiding treatment intervention.

Scoring: add up all checked boxes on PHQ-9

For every 3 Not at all = 0; Several days = 1;

More than half the days = 2; Nearly every day
=3

Interpretation of Total Score

Total Score Depression Severity

1-4 Minimal depression
5-9 Mild depression
10-14 Moderate depression
15-19 Moderately severe depression
20-27 Severe depression

PHQ9 Copyright © Pfizer Inc. All rights reserved. Reproduced with permission. PRIME-MD ®
is a trademark of Pfizer Inc.

A2662B 10-04-2005

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