Depressive and Anxiety Symptoms among Pregnant Women in Beni-Suef Governorate, Egypt.

doi:10.21203/rs.3.rs-4850467/v1

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Depressive and Anxiety Symptoms among Pregnant Women in Beni-Suef Governorate, Egypt.

https://doi.org/10.21203/rs.3.rs-4850467/v1

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Background

Depression and anxiety during pregnancy are documented significant public health issues. Therefore, the aim of the study is to detect the prevalence of anxiety and depressive symptoms during pregnancy in Beni-Suef Governorate and to determine the risk factors associated with them. A ten-month analytical cross-sectional study was performed on 434 pregnant women who regularly attended the antenatal care clinic at the Beni-Suef University Hospital and six others randomly chosen health care facilities in the governorate of Beni-Suef. The Arabic versions of the Hamilton Anxiety Rating Scale (HAM-A) and Hamilton Rating Scale for Depression (HDRS), as well as a structured questionnaire, were employed.

Results

Prevalence of prenatal depressive and anxiety symptoms was found to be respectively 73.5% and 33.9%, and their occurrence was related to the pregnant woman's place of residence, educational level, and husband's educational level as well as the fetus' gender, history of complications in the current pregnancy, and psychiatric symptoms in the current pregnancy.

Conclusion

Preventive healthcare initiatives are required to enhance pregnant women's mental health.

Antenatal

Anxiety

Depression

Pregnancy

Prevention

Screening

According to a review, the most prevalent mental health issues in the perinatal period are depression and anxiety. From 10 to 15 pregnant women out of every 100 are said to be depressed. The most prevalent mental health issues among these women recently have been prenatal mood and anxiety disorders [1].

Due to their great frequency, depression and anxiety during pregnancy are significant public health issues. Significantly higher prevalence rates of depression have been observed in pregnancy particularly in the second and third trimesters [2]. The fact that a large proportion of pregnant women attending prenatal clinics suffered from depression and anxiety throughout pregnancy, as well as the factors linked with them, highlighted the need for screening for these illnesses and the factors related with them [3].

Important risk factors for mental morbidities during pregnancy have been recognized as stressful life events, a lack of social support, and a history of depression [4].

Due to the potential effects on both the mother's and the child's health, antepartum mental health concerns are a public health concern [5]. The risks of preterm birth, low birth weight, and perinatal death are modestly elevated in depressed women [6]. Obstetric, fetal, and perinatal outcomes may be negatively impacted by anxiety disorders during pregnancy [7]. Improving maternal mental health during pregnancy is a crucial part of preventing adverse health and developmental outcomes in infants and children [8].

Study aim, site, and design:

A ten-month cross-sectional analytical study on pregnant women who regularly attended antenatal care appointments in the governorate of Beni-Suef. The aim of the current study was to detect the prevalence of anxiety and depressive symptoms during pregnancy in Beni-Suef Governorate and to determine the risk factors associated with them.

Sample size and sampling technique:

Multistage random sampling was used as the sample method. Beni-Suef governorate is composed of seven major districts. Firstly, from the seven districts in Beni-Suef governorate two districts were selected randomly: Beni-Suef district and Naser district. Secondly in Beni-Suef district, two out of 27 primary health care centers (El-kom El-ahmar and El mermah health care centers), and two out of four health offices (El Ghamrawy and Sharq El-Nile health offices) were selected randomly in addition to Beni-Suef university hospital ANC clinic. From Naser City, two health care facilities were selected randomly: Bani-adi primary health care center and Naser health office.

With a 95% confidence level, a 5% acceptable margin of error, one design effect, and a 50% predicted frequency of depression and anxious symptoms during pregnancy, the sample size for the population survey was determined using Epi info stat-calc. There were at least 384 pregnant women in the calculated sample size, it was discovered. To boost the study's power, the sample size was raised.

Administrative and Ethical Issues:

The study proposal was approved by the faculty of medicine

Beni-Suef University Ethics Committee in April 2021 (Approval No: FMBSUREC\06042021\Mahmoud). All participants completed the informed consent forms after being educated about the study's goals and objectives, and they were informed that their participation was entirely voluntary.

Study tools:

A structured survey produced in Arabic using the sections listed below: The socio-demographic details, medical history, and obstetric background of the study subjects were included in Section 1. The participants' psychiatric histories from their prior and current pregnancies as well as any family history of psychiatric disease were included in Section 2 of the study. The validated Arabic Hamilton Anxiety Rating Scale (HAM-A), which comprises of 14 closed-ended questions, was used in Section 3. Each question contained five options on the Likert scale, ranging from zero (not present) to 4 (severe), for a possible total score of zero to 56. The score was interpreted as follows: a score of 17 or less indicated mild anxiety severity, a score of 18 to 24 mild to moderate anxiety severity, a score of 25 to 30 moderate to severe anxiety, and a score of > 30 severe symptoms.

In 1994, Fatim translated it from the English language into Arabic [9]. Moreover, Hallit et al. in Lebanon have verified the Arabic version [10]. High reliability and validity are present in the Arabic version [11, 12].

The validated Arabic Hamilton Rating Scale for Depression (HDRS), which comprises of 17 closed-ended questions, was used in Section 4. Nine questions with three answers receive scores ranging from (0–2) for eight questions with five answers, and (0–4). The Hamilton Rating Scale for Depression (HRSD) was scored using the following system. Each response to a survey question has a code that ranges from 0 to 4 or 0 to 2. EPDS Overall Scoring from zero to 30; (zero to 7 points were considered normal), (8–13 points were considered as a mild grade of depression), (14–18 points were considered as a moderate grade of depression), (19–22 points were considered as a severe grade of depression) and (≥ 23 points as Very Severe \profound depression), [13]. Consequently, higher scores denote severe depression.

Data collection, management and analyses:

Firstly, a pilot study was conducted on 50 participants at El Ghamrawy health office during June 2021 aiming to test the questionnaire. For illiterate women the researcher read out the questionnaire and noted their responses. After the pilot study, the questionnaire's final form had not undergone any adjustments.

All collected questionnaires were edited for completeness and logical consistency before being transferred to the Statistical Package for Social Science Software, version 26 (SPSS) for statistical analysis. Description of qualitative variables was by the count and percentage and quantitative variables by the mean and standard deviation (mean ± SD). Chi-square (χ²) test was used for detection of association between high probability of anxiety depressive symptoms during pregnancy and different categorical baseline characteristics. Pearson correlation coefficient was used to assess the strength of a linear association between two quantitative variables. Significance level (P) was determined at P value ≤ 0.05.

The current study enrolled 434 pregnant women. About (94.0%) of them were more than 20 years old and (65%) reside in rural communities. About (39.9%) were with university and postgraduate. More than one-half of participants had got married ≥ 20 years old (57.8%) and were housewives (65.9%). About (40.8%) of the husbands were with university education and the largest percentage of them was working (95.9%). The largest percentage of the studied pregnant women had a stable relationship in their families with no domestic violence (79.0%) and (91.2%) respectively.

Regarding Medical and Obstetric History of the Studied Pregnant Women, only 65 pregnant women (15%) have different medical health problems. The largest percentage of the studied women were multigravida (59.4%) with a mean equal 2.9 ± 1.8 SD. A bout (53.0%) of the studied pregnant women in the third trimester, had planned for this current pregnancy (68%) and had no complications in the current pregnancy (73.7%).

Regarding psychiatric history, the largest percentage of the studied pregnant women had no previous history of psychiatric illness (73.5%), no postpartum depression (83.4%), and no family history of psychiatric illness (95.9%). Moreover, the largest percentage of them reported that they had no current history of psychiatric symptoms and no need for psychiatric consultation (43.8%) and (70.7%), respectively.

Table (1) and Figure (1) demonstrated the distribution of the studied pregnant women regarding the Hamilton Anxiety Rating Scale (HAM-A) according to the cutoff point 17. One third of pregnant women (33.9) had anxiety symptoms with ranging degrees. The largest percentage of them had mild severity of Anxiety symptoms (66.1%).

Table (1): Distribution of the Studied Pregnant Women according to Hamilton Anxiety Rating Scale (HAM-A)

Anxiety Score	Frequency (no)	Percentage (%)
Mild anxiety symptoms ≤ 17	287	66.1
Clinical anxiety symptoms:	147	33.9
Mild to moderate (18–24)	83	19.1
Moderate to severe (25–30)	40	9.2
Severe (> 30)	24	5.5
Total	434	100

The distribution of the studied pregnant women regarding the Hamilton Depression Rating Scale (HDRS) was demonstrated in table 2 and Fig. 2. Nearly ¾ of pregnant women have depressive symptoms (73.5%). The largest percentage of them, nearly one third, had mild depressive symptoms (32.9%).

Table (2): Distribution of the Studied Pregnant Women according to The Hamilton Depression Rating Scale (HDRS)

Depression Score	Frequency (no)	Percentage (%)
Normal (0–7)	115	26.5
Depressed (have depressive symptoms)	319	73.5
Mild (8–13)	143	32.9
Moderate (14–18)	100	23.0
Severe (19–22)	42	9.70
Very severe\Profound (≥ 23)	34	7.80
Total	434	100.0

Figure (3) demonstrated that the largest percentage of the studied pregnant were depressed only (40.6%), followed by both anxious and depressed (32.9%). While only 0.9% of women were anxious only.

Multivariable logistic regression analysis was done to assess sociodemographic, obstetric, and psychiatric history factors that can be associated with anxiety and depression occurrence among the studied pregnant women. And odds ratios (OR) with their corresponding confidence intervals (CI) were calculated. The consequent variables were involved in the regression model: residence (rural versus urban), age (≤ 20 versus > 20 years), marital age (≤ 20 versus > 20 years), education (illiterate and preuniversity versus university and postgraduate), occupation (housewife versus working), husband education (illiterate and preuniversity versus university and postgraduate), husband occupation (non-working versus working), gravidity (primigravida and multigravida versus grand multigravida), planning of pregnancy (planned versus non-planned), complication of current pregnancy (present versus absent), living home (family versus separate), familial stability (present versus absent), exposure to domestic violence (present versus absent), trimester of pregnancy ( first and second versus third), gender of fetus (male, female, and twin versus unknown), History of Postpartum depression (present versus absent), Family history of psychiatric illness (present versus absent), Previous psychiatric illness (present versus absent),and Current psychiatric illness (present versus absent).

In the multivariable logistic regression model, pregnant women residing in rural communities were less likely to be anxious than their counterparts residing urban communities (OR = 0.49, P value = 0.025). Pregnant women with preuniversity education were less liable to be anxious compared with their complements with university and postgraduate education (OR = 0.357, P value = 0.049). Pregnant women of illiterate husbands and who are with preuniversity education husbands were more liable to be anxious than pregnant women whose husbands had university or postgraduate education (OR = 3.58, P value = 0.028) and (OR = 2.73, P value = 0.037), respectively. Pregnant women with non-complicated current pregnancy were less liable to be anxious during pregnancy than their complements (OR = 0.45, P value = 0.003). Moreover, pregnant women in the first trimester were less liable to be anxious than those in the third trimester (OR = 0.242, P value = 0.005). Pregnant women with known fetus gender either male or female gender were less liable to be anxious than those with unknown gender of the fetus (OR = 0.35, P value = 0.021) and (OR = 0.289, P value = 0.006), respectively. On the contrary, pregnant women with current psychiatric illness were more liable to be anxious than their counterparts without psychiatric illness (OR = 5.29, P value = 0.001), (Table 3).

Table (3): Predictors of Anxiety among the studied pregnant women

Characteristics			P value	Adjusted OR	95% C.I.
Characteristics			P value	Adjusted OR	Lower	Upper
Rural residence			0.025	0.499	0.273	0.915
Age ≤ 20 years			0.134	2.208	0.784	6.218
Age at marriage ≤ 20 years			0.700	1.133	0.600	2.140
Education	Illiterate		0.101	0.364	0.109	1.216
	Preuniversity		0.049	0.357	0.128	0.994
	University and postgraduate		REF
Housewife			0.251	1.433	0.775	2.651
Husband Education	Illiterate		0.028	3.582	1.147	11.184
	Preuniversity		0.037	2.731	1.060	7.037
	University		REF
Non-working husband			0.306	0.520	0.148	1.821
Unplanned pregnancy			0.260	0.735	0.430	1.256
Non-complicated current pregnancy			0.003	0.450	0.266	0.764
Living Home	Family home		0.907	0.968	0.558	1.679
Living Home	Separate home		REF
Family stability			0.319	0.721	0.378	1.373
Domestic violence			0.823	0.898	0.352	2.292
Trimester of pregnancy	First trimester		0.005	0.242	0.090	0.651
	Second trimester		0.276	0.715	0.391	1.307
	Third trimester		REF
Gender of fetus	Male		0.021	0.356	0.148	0.853
	Female		0.006	0.289	0.119	0.702
	Twin		0.794	1.180	0.340	4.100
	Unknown		REF
History of Postpartum depression			0.538	1.244	0.620	2.496
Family history of psych illness			0.059	2.985	0.957	9.309
Previous psychiatric illness			0.376	1.322	0.712	2.455
Current psychiatric illness			0.001*	5.297	3.120	8.994
Gravidity		Primigravida	0.502	0.727	0.286	1.844
		Multigravida	0.170	0.606	0.296	1.240
		Grand multigravida	REF

*P-value is considered significant at p ≤ 0.05

On the other hand, the multivariable logistic regression model for prediction of depression among the studied pregnant women revealed that pregnant women ≤ 20 years old were less liable to be depressed than their counterparts > 20 years old (OR = 0.227, P value = 0.006). While pregnant women with current psychiatric illness were more liable to be depressed compared with their counterparts without psychiatric illness (OR = 4.86, P value = 0.001), (Table 4).

Table (4) Predictors of depression among the studied pregnant women

Characteristics		P value	Adjusted OR	95% C.I.
Characteristics		P value	Adjusted OR	Lower	Upper
Rural residence		0.657	1.159	0.604	2.223
Age ≤ 20 years		0.006*	0.227	0.079	0.648
Age at marriage ≤ 20 years		0.773	1.101	0.571	2.125
Education	Illiterate	0.401	0.611	0.193	1.930
	Preuniversity	0.656	0.803	0.306	2.108
	University	REF
Housewife		0.251	1.433	0.775	2.651
Husband education	Illiterate	0.596	0.752	0.262	2.156
	Preuniversity	0.518	1.331	0.559	3.168
	University	REF
Non-working husband		0.880	1.101	0.318	3.808
Unplanned pregnancy		0.066	0.593	0.339	1.036
Non-complicated current pregnancy		0.377	0.758	0.411	1.401
Living Home	Family home	0.412	0.785	0.441	1.398
Living Home	Separate home	REF
Family stability		0.474	0.770	0.377	1.575
Domestic violence		0.087	2.596	0.872	7.733
Trimester of pregnancy	First trimester	0.755	1.163	0.450	3.007
	Second trimester	0.156	0.643	0.350	1.183
	Third trimester	REF
Gender of fetus	Male	0.848	0.919	0.386	2.185
	Female	0.524	0.757	0.322	1.783
	Twin	0.474	0.612	0.160	2.346
	Not known	REF
History of Postpartum depression		0.502	1.341	0.570	3.158
Family history of psych illness		0.152	4.746	0.563	40.008
Previous psychiatric illness		0.498	1.280	0.626	2.619
Current psychiatric illness		0.001*	4.864	2.906	8.142
Gravidity	Primigravida	0.911	0.945	0.349	2.560
	Multigravida	0.701	0.858	0.393	1.874
	Grand multigravida	REF

*P-value is considered significant at p ≤ 0.05

Pearson correlation analysis was used to determine the relationship between anxiety and depression among the investigated pregnant women, and it revealed a substantial positive relationship between anxiety and depression grades., (P-value = 0.001, r = 0.77), Table 5& Fig. 4.

Table (5): Correlation between the Scores of Anxiety and Depression of the Studied Pregnant Women

	Mean	SD	P value	Correlation Coefficient (r)
Anxiety Score (0–30)	14.8	± 8.39	0.001*	0.77
Depression Score (0–56)	12.4	± 6.78	0.001*	0.77

*P-value is considered significant at p ≤ 0.05

Figure 3 from the current study shows that 32.9% of pregnant women experienced both anxiety and depressed symptoms at the same time. This result is consistent with a sectional study that was conducted in 2013 and involved 376 pregnant women who were attending the antenatal care outpatient clinics at Kasr Al-Ainy University Hospital in Cairo, Egypt. The study used the Hurt, Insulted, Threaten, Scream (HITS) inventory and the Hospital Anxiety and Depression Scale questionnaire and found that a higher percentage of women (63%) had concurrent anxiety and depressive manifestations. In contrast, only a tiny percentage of them (11.4% and 10.4%, respectively) showed solely anxiety and alone depression [14]. The increased incidence of depression and anxiety symptoms individually in the current study could be attributed to differences in the study settings, assessment tools, sociocultural, and psychological factors that may vary throughout the country.

Methodological and cultural variations may be to blame for the current study's increased prevalence of prenatal anxiety symptoms. This may be due to the fact that LMIC settings have greater incidence of prenatal anxiety disorders than HIC settings [15]. The study's pregnant participants experienced the COVID-19 pandemic while they were pregnant, which may have increased their anxiety about both their own health and the health of their unborn children.

• Sociodemographic characteristics in relation to the anxiety scores

The domicile of the pregnant women who were the subject of the study and the pregnancy-related anxiety symptoms differed statistically significantly (P-value = 0.025). According to Table 3, pregnant women living in rural areas are less liable to experience anxiety than those who are living in urban communities (OR = 0.49, 95% CI: 0.273–0.915). The view that urbanization increases stress and anxiety can be used to support this.

Also, there was a statistically significant relationship (P-value = 0.049) between the tested women's educational degree and their anxiety symptoms. Compared to their peers with university and postgraduate education, pregnant women with preuniversity education were less liable to suffer anxiety (OR = 0.357, 95% CI: 0.128–0.994), Table 3.

In contrast, a Hungarian study survey found that women with less education than a vocational level had more anxiety symptoms than those with high school, university, and all other levels of education [16]. The difficulty of postgraduate coursework and its effects on students' lives in terms of stress and anxiety can be attributed to this in the current study.

Pregnant women with illiterate husbands and those whose husbands had pre-university education were more likely to experience anxiety than those whose husbands had university or postgraduate education (OR = 3.58, 95% CI: 1.147–11.184) and (OR = 2.73, 95% CI: 1.06–7.04), respectively. There was a statistically significant relationship between anxiety symptoms and husband's education (P-value = 0.049).

This can be explained by the concomitant poor income or financial difficulties, which have been identified as major variables in certain studies [17, 18]. Low socioeconomic status is connected with lower levels of education, and persons who share these traits lack the resources and information needed to improve their pregnancy conditions [19].

• Obstetric history in relation to anxiety scores

The current challenging pregnancy and the signs of anxiety during pregnancy differ statistically significantly (P-value = 0.003). In comparison to their peers, pregnant women with an uncomplicated current pregnancy were less likely to have anxiety throughout pregnancy (OR = 0.45, 95% CI = 0.266–0.764), Table 3. Similar studies showed that prenatal anxiety was more prevalent in women who were currently experiencing pregnancy difficulties [17, 18].

Furthermore, gestational age was associated with prenatal anxiety symptoms in the pregnant women studied (P-value = 0.005). According to table 3, first-trimester pregnant women were less likely than third-trimester pregnant women to be anxious (OR = 0.242, 95% CI: 0.09–0.65). The previous conclusion is congruent with a descriptive cross-sectional study that used the Hospital Anxiety Subscale on 209 pregnant women from a municipality in Brazil. Anxiety was more widespread in the third trimester, affecting 26.8% of pregnant women [20]. In studies conducted in Italy [21] and Australia [22], other researchers reached similar outcomes.

Given that the third trimester of pregnancy is more stressful for women due to this closeness to delivery, higher anxiety rates in the final trimester of pregnancy may be ascribed to this closeness [23]. The preceding finding may be explained by the fact that some pregnant women regard pregnancy and labor as vulnerable times that might elicit feelings of fear in women [24], sensations that can present in both women who have had previous births and those who have not (first-time mothers). Fear is normal during pregnancy, but it can become stronger as the due date nears. This predisposes the pregnant lady to alterations in her psychological well-being because research indicates that women who are terrified of childbirth are more likely to experience depression.

• Psychiatric history in relation to anxiety scores

In the current pregnancy, there is a statistically significant difference (P-value = 0.001) between anxiety symptoms and psychiatric symptoms. In comparison to their peers without psychiatric illness, pregnant women with psychiatric illness were more liable to suffer anxiety (OR = 5.29, 95% CI: 3.12–8.99), table 3. A history of mental illness during the present pregnancy was not linked to prenatal anxiety, according to prior research [26, 27]. Many settings that are deficient of comprehensive mental health care misdiagnose or treat many women with common mental diseases.

The current study's greater prevalence of depression symptoms (73.5%) is comparable to a recent cross-sectional study carried out in Shebein el Kanater, Qaliobia Governorate, Egypt.

The previous study, which employed the same scale, HRSD, covered 300 pregnant women in the third trimester. It was discovered that two-thirds (68.7%) of the participating rural women—who were reportedly healthy and free of medical issues after being examined by an obstetrician—had antepartum depression in varying degrees [28].

Contrarily, a lower prevalence of antepartum depression was reported in Australia (7%) [29] and Hong Kong (4.4%) [30]. In addition, it was noted that the prevalence of prenatal depression was low in Riyadh City, Saudi Arabia (18.6%) and Tanzania (33.8%) [31, 32]. The sociodemographic and economic disparities between the present study and the studies from other nations may be the cause of the differences in the prevalence of antepartum depression. Additionally, methodological variations between studies, such as the kinds of screening tools utilized, the gestational time point when symptoms were checked for, sample size, and various sampled groups, may contribute to such variations. Also, because fewer depressed mothers participated in the study, it's possible that the prevalence of antepartum depression was underestimated. They may have avoided stigma associated with mental illness because of their fear, denial, and avoidance of it. The failure to seek mental health services could also be a result of depression symptoms being confused for pregnancy-related hormonal and physiological changes.

• Sociodemographic characteristics in relation to the depressive symptoms:

Maternal age and depressive symptoms are significantly correlated in the current study (P-value = 0.006). According to table 4, pregnant women under the age of 20 were less liable than those beyond the age of 20 to have depression (OR = 0.227, 95% CI: 0.079–0.648). In a similar vein, the increase in age was found to be an associated factor for depression in a descriptive research of 165 pregnant women at The Aga Khan University Hospital in Karachi, Pakistan [33], as well as in the reproductive age group [34].

• Psychiatric History in relation to the depressive scores:

In the current pregnancy, there is a statistically significant difference between depressive symptoms and a history of psychiatric symptoms (P-value = 0.001). According to the study, pregnant women with present psychiatric illness were more liable to experience depression than their non-psychiatric participants (OR = 4.86, 95% CI: 2.91–8.14), according to table 4. This concurs with findings from earlier investigations [35, 36]. Additional research has shown that anxiety significantly increases the chance of developing depression when pregnant [37, 38]. However, that was not revealed by another investigation [39].

The limitations of the current research involve the self-reported character of the responses, which may account for other factors like happiness with current life and the high frequency of anxiety and sadness. Moreover, a higher prevalence may be explained by the similarities between anxiety, depressive symptoms, and physiological changes during pregnancy. The cross-sectional study design, which makes it impossible to establish a link between pregnancy, anxiety, and depression.

In conclusion, pregnancy and parenting are often good psychological experiences for women. But for some women, this life-altering experience might lead to a mental health issue. According to the results of the current study, prenatal anxiety symptoms affect 33.9% of participants, whereas depressive symptoms affect nearly three-fourths of pregnant women (73.5%).

Pregnancy-related symptoms of depression and anxiety are widespread, although less is known about them in low- and middle-income nations. Knowing the causes of these conditions makes it possible to establish preventative prenatal care strategies, which is regarded as an ideal setting for developing interventions aimed at enhancing the mental health of expectant mothers and their unborn children. Also, the pregnant woman should receive psychological support from her spouse, her family, and the community at large. Pregnant women should get appropriate health education regarding depressed and anxiety symptoms during pregnancy and how to prevent them.

HAM-A

Hamilton Anxiety Rating Scale

HDRS

Hamilton Rating Scale for Depression

HITS

Hurt, Insulted, Threaten and Scream inventory

Author Contribution

HS and EAE conceived and designed the study. SK and HS constructed, distributed and collected the questionnaires. GSA analyzed and interpreted data. EMK, AM, and GSA wrote the initial and final draft of the manuscript. All authors reviewed the manuscript and are responsible for the content .

Acknowledgement

The authors would like to thank all females participated in the study

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No competing interests reported.

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Depressive and Anxiety Symptoms among Pregnant Women in Beni-Suef Governorate, Egypt.

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Abstract

Background

Results

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BACKGROUND

SUBJECTS AND METHODS

Study aim, site, and design:

Sample size and sampling technique:

Administrative and Ethical Issues:

Study tools:

Data collection, management and analyses:

RESULTS

Discussion

• Sociodemographic characteristics in relation to the anxiety scores

• Psychiatric history in relation to anxiety scores

• Sociodemographic characteristics in relation to the depressive symptoms:

• Psychiatric History in relation to the depressive scores:

Conclusions

Abbreviations

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Acknowledgement

References

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