|Year : 2019 | Volume
| Issue : 4 | Page : 283-287
A cross-sectional study of comorbid depression in patients with chronic tension-type headache in psychiatry outpatient
Ajinkya Ghogare1, Ashish Saboo2
1 Department of Psychiatry, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
2 Department of Psychiatry, Panjabrao Deshmukh Memorial Medical College, Amravati, Maharashtra, India
|Date of Submission||19-Jul-2019|
|Date of Decision||28-Aug-2019|
|Date of Acceptance||03-Sep-2019|
|Date of Web Publication||16-Jul-2020|
Dr. Ajinkya Ghogare
House Number 4, Shree Colony, Daryapur, Amravati - 444 803, Maharashtra
Source of Support: None, Conflict of Interest: None
Context: Headache is one of the most common reasons for which patients seek medical attention. Headache is a common neurological disorder that ranks among the top 10 most disabling conditions for both men and women worldwide. Psychiatric comorbidities have been commonly observed in patients with tension-type headache (TTH) and that may be explained by affective distress, personality disorders, and maladaptive coping. Aim: The aim was to study the prevalence and severity of comorbid depression in patients with chronic TTH. Materials and Methods: The present cross-sectional study was conducted at a tertiary health-care center in Central India, with a sample size of 95. Data from selected study participants were recorded in a predesigned, semi-structured questionnaire. The Hamilton Depression Rating Scale (HDRS) was used to categorize depression. Results: Out of total 95 study participants, majority (45 [47.4%]) were in the age group of 31–40 years, with a mean age of 36.67 years, a standard deviation of 7.14 years, and range between 21 and 56 years. Higher proportions of female study participants (67 [70.5%]) were observed than male study participants (28 [29.5%]). A majority of the study participants were married (74 [77.9%]) and 57 (60.0%) were employed. The prevalence and severity of depression, according to the HDRS, was mild depression in 31 (32.6%), followed by moderate depression in 16 (16.8%), and severe depression among 3 (3.2%) cases. Conclusion: TTH is associated with comorbid depression in 52.6% of the study participants. Married patients had high frequency of depression. No other sociodemographic characteristics were associated with the presence of depression.
Keywords: Depression, Hamilton Depression Rating Scale, stress, tension-type headache
|How to cite this article:|
Ghogare A, Saboo A. A cross-sectional study of comorbid depression in patients with chronic tension-type headache in psychiatry outpatient. J Datta Meghe Inst Med Sci Univ 2019;14:283-7
|How to cite this URL:|
Ghogare A, Saboo A. A cross-sectional study of comorbid depression in patients with chronic tension-type headache in psychiatry outpatient. J Datta Meghe Inst Med Sci Univ [serial online] 2019 [cited 2020 Aug 8];14:283-7. Available from: http://www.journaldmims.com/text.asp?2019/14/4/283/289783
| Introduction|| |
Headache is one of the most common reasons for which patients seek medical attention, on a global basis being responsible for more disability than any other neurologic problem. Every year, about 80% of the population has at least one episode of headache, and 10%–20% go to a physician with headache as their primary complaint. Headache is a common neurological disorder that ranks among the top 10 most disabling conditions for both men and women worldwide. Headache patients, especially those with migraine or chronic daily headache, tend to show reduced quality of life.
Most workups for common headache complaints have negative findings, and such results may be frustrating for both the patient and the physician. Physicians not well versed in psychological medicine may attempt to reassure such patients by telling them that they have no disease. However, this reassurance may affect patients in the opposite way; it may increase the patient's anxiety and even escalate into a disagreement about whether the pain is real or imagined.
The association between headache and psychiatric disorders is common with depression, with bipolar disorders, anxiety, and somatoform disorders being the most common complaints. Psychiatric comorbidities have been commonly observed in patients with tension-type headache (TTH) and that may be explained by affective distress, personality disorders, and maladaptive coping.
TTH is one of the most common primary headaches, with a prevalence ranging from 30% to 78% worldwide, and among them, majority have an infrequent episodic type and 2%–3% of patients have a chronic type.,,, Depression is the most commonly recognized comorbidity present in patients with TTH.
The HADAS study, published in 2011, compared the prevalence of psychiatric comorbidities in migraine without aura, TTH, and combined headache. The study showed that 12.8% of patients with TTH had psychiatric comorbidities, of whom, 67% had a depressive episode, 19.3% had anxiety disorders, 5.5% had panic disorder, and 1.1% had an obsessive-compulsive disorder.
The presence of psychiatric comorbidity in headache further complicates and makes headache management more difficult and portends a poorer prognosis for headache treatment. On doing a review of literature, data on this topic from central India are scarce, hence the need for further comprehensive studies on chronic TTH with psychiatric comorbidities in Central India. Therefore, this study was carried out with an intent to study the prevalence and severity of comorbid depression in patients with chronic TTH.
| Materials and Methods|| |
The present cross-sectional observational study was conducted in the department of psychiatry of a tertiary health-care center. Patients presenting to the psychiatric outpatient department complaining of headache were included as the study population. All the patients with headache attending the hospital were sent to psychiatry outpatient for initial evaluation. From these patients, the study participants were recruited on the basis of a simple random sampling frame. The study participants were recruited prospectively. The study period was of 6 months, from April to September 2017. The final number of study participants was 95.
Inclusion criteria adopted for the study were (i) patients aged >18 and <60 years, (ii) patients fulfilling criteria for chronic TTH as per the International Classification of Headache Disorders – 2 criteria, and (iii) patients giving consent for the study. Exclusion criteria were (i) patients with severe mental disorders such as dementia, schizophrenia, and mental retardation; (ii) patients with severe neurological disorders such as head injuries and space-occupying lesions as well as degenerative conditions ruled out on computed tomography of brain; and (iii) pregnant women.
Data from the selected study participants were recorded in a predesigned, semi-structured questionnaire. It was used to record the sociodemographic data (name, age, marital status, occupation, address, etc.) and the findings of general examination, systemic examination, and mental status examination of the patients. The Hamilton Depression Rating Scale (HDRS) was used to categorize depression. The HDRS has 17 items. Eight items are scored from 0 to 4, whereas the further nine items are scored from 0 to 2. For categorization purpose, the HDRS score of <7 indicates no depression, 8–16 indicates mild depression, 17–23 indicates moderate depression, and >24 indicates severe depression.,,
Prior to the start of the study, permission from the institutional ethics committee was obtained. Informed written consent was taken from all the study participants.
Data from the questionnaire were entered and cleaned with the help of Microsoft Excel version 2007. The final data were analyzed with the help of SPSS statistical software version 16 (IBM, Chicago, Illinois, USA). Continuous data were presented as mean and standard deviation (SD). Categorical data were presented as frequency and percentage. Chi-square test was used to determine the level of significance.
Ethical clearance was obtained from the Institutional Ethical Committee of JNMC, Sawangi (Meghe), Wardha, on 28th May 2019. With ethical clearance no DMIMS(DU)/IEC/2019-20/348.
| Results|| |
[Table 1] shows the sociodemographic variables. Forty-five (47.4%) study participants were in the age group of 31–40 years, whereas 23 (24.2%) participants were in the age group of 41–50 years. The mean age of the study participants was 36.67 years, with an SD of 7.14 years and range between 21 and 56 years. Higher proportions of female study participants (67 [70.5%]) were observed than male study participants (28 [29.5%]). A majority of the study participants (74 [77.9%]) were married. A majority of the study participants (57 [60.0%]) were employed in various kinds of occupation, followed by unemployed (38 [40.0%]).
[Table 2] summarizes the prevalence and severity of comorbid depression among the study participants, according to the scores on the HDRS. Mild level of depression was found in 31 (32.6 %) study participants, followed by a moderate level of depression in 16 (16.8 %) and severe level of depression among 3 (3.2 %). No depression was seen among 43 (45.3%) study participants.
|Table 2: Distribution of the study participants according to the scores on the Hamilton Depression Rating Scale|
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[Table 3] shows the distribution of the study participants, with an association of the sociodemographic variables with depression according to the HDRS. Among the study participants, those who were <40 years of age, 23 (34.3%), had mild comorbid depression, 8 (11.9%) had moderate comorbid depression, and 1 (1.5%) study participant had severe comorbid depression, whereas 35 (52.2%) had no comorbid depression. Among those who were above the age of 40 years, 8 (28.6%) had mild comorbid depression, another 8 (28.6%) had moderate comorbid depression, and 2 (7.1%) had severe comorbid depression, whereas 10 (35.7%) had no comorbid depression. Among the female population with chronic TTH, 23 (34.3%) had mild, 8 (11.9%) had moderate, and 1 (1.5%) had severe comorbid depression, whereas 35 (52.2%) had no comorbid depression on the HDRS. Among the male population with chronic TTH, 8 (28.6%) had mild, another 8 (28.6%) had moderate, and 2 (7.1%) had severe comorbid depression, whereas 10 (35.7%) had no comorbid depression as per the score on the HDRS. Among employed study participants, 17 (29.8%) and 11 (19.3%) had mild and moderate comorbid depression, respectively, whereas 29 (50.9%) had no comorbid depression. Among the unemployed, 14 (36.8%), 5 (13.2%), and 3 (7.9%) had mild, moderate, and severe comorbid depression, respectively, whereas 16 (42.1%) had no comorbid depression. Among the married study participants, 27 (36.5%), 15 (20.2%), and 1 (1.4%) had mild, moderate, and severe comorbid depression, respectively, whereas 31 (41.9%) had no comorbid depression. Among the unmarried, 4 (19.0%), 1 (4.8%), and 2 (9.5%) had mild, moderate, and severe comorbid depression, respectively, whereas 14 (66.7%) had no comorbid depression.
|Table 3: Distribution of sociodemographic variables with severity of depression according to scores on the Hamilton Depression Rating Scale|
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[Table 4] shows that the difference between HDRS scores of patients younger than 40 and older than 40 years was not statistically significant. Similarly, there was no statistically significant difference in HDRS scores among female and male genders.
|Table 4: Distribution of sociodemographic variables to the scores on the Hamilton Depression Rating Scale|
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On the occupation variable, there was no statistically significant difference between the employed and unemployed study participants as regards the HDRS score. Married study participants had higher HDRS score compared to unmarried participants, and the difference was statistically significant.
| Discussion|| |
The present study showed that nearly half of the study participants suffer from depression, according to the HDRS.
In the present study, the highest number of study participants (45 [47.4%]) were in the age group of 31–40 years, with a mean age of 36.67 years and an SD of 7.14 years, whereas Bhuvana found that 78% of the study participants belonged to the age group of 20–40 years with a mean age of 32.01 years. The study conducted by Singh et al. found the mean age of presentation to be 30.2 years with an SD of 10.3 years.
The present study comprised 28 (29.5%) male study participants and 67 (70.5%) female study participants. The study conducted by Singh et al. comprised 28 male and 64 female study participants, which was consistent with the present study findings. Jain et al. conducted a study and found out that 62.4% were female while 37.6% were male study participants.As regards occupation status, in the present study 60.0% patients were employed and 40.0% were unemployed. We have included housewives in unemployed category. While Jain AP et al observed that majority of patients with TTH (41.1%) were housewives.
 This might reflect that being employed and being housewife imparts more perceived stress and the perceived stress might lead to increased impact of TTH among employed population as well as housewives.
In this study, 74 (77.9%) study participants were married, whereas 21 (22.1%) were unmarried. A study by Jain et al. showed higher rate of headache and psychiatric comorbidity in married (69.3%) than in unmarried patients, which is consistent with our study findings.
The overall prevalence of psychiatric comorbidity as depression among the patients presenting with chronic TTH was 54.7%, which was assessed by using the HDRS in our study. Bera et al. reported that the psychiatric comorbidity in patients with TTH was 60.0%, in which depression was most common.,,,,, Singh et al. found psychiatric comorbidity as depression in 53.3% of the patients presenting with chronic daily headache in their study, which was similar to the present study finding.
Out of 54.7% of study participants diagnosed as having comorbid depression, 32 (33.7%) had mild depression, 31 (32.6 %) had mild depression, 16 (16.8 %) had moderate depression, and 3 (3.2 %) had severe depression.
We have utilized the HDRS to find out the prevalence and severity of the comorbid depression among patients with chronic TTH was 52.6 %, which can be utilized in the better treatment of the similar patient population.
The study has not included the association between different types of depressive disorders and chronic TTH. Treatment of chronic TTH and comorbid depression was not considered in the study owing to the cross-sectional nature of the study.
| Conclusion|| |
Comorbid depression is the most predominant psychiatric disorder among patients presenting with chronic TTH. Age >40 years (64.3%), male gender (64.3%), unemployed status (57.9%), and married status (58.1%) are most likely to agonize from comorbid depression among patients presenting with chronic TTH. However, differences are not statistically significant among the given sociodemographic parameters except the parameter of marital status. Thus, as regard age, gender, and occupation, secular trends are observed in comorbid depression among patients with chronic TTH.
These results emphasize the importance of determining comorbid depression in the clinical prognosis and treatment of chronic TTH to stop further morbidity. Further research is needed regarding the types of comorbid depressive disorders and their impact on the management of patients with chronic TTH.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]