Prevalence of Major Depressive Disorder (MDD) among study participantsBased on the Self Report Questionnaire (SRQ) of the total study participants (374) those who scored 6 and above on the SRQ were 191(51%) CI (0.46, 0.56) indicating psychological distress.

The prevalence of Major Depressive Disorder was 174 (46.52%) among the study population of the urban refugees attending the Inter-Aid Centre in Kampala city, Uganda. Out of these, 138 (79.31%) had low suicidal risk, 32 (18.39%) moderate risk and 4 (2.30%) had high suicidal risk. The factors independently associated with Major Depressive Disorder were older age, (aOR 6.56, 95% CI 1.25-34.44, p= 0.026), suicidal risk score (aOR 1.63, 95% CI 1.04-2.57, p= 0.034), perceived social support (aOR 0.8, 95% CI 0.71-0.90; p=0.001), positive coping skills (aOR 0.61, 95% CI 0.45-0.82; p=0.001) and negative coping skills (aOR 1.96, 95% CI 1.31-2.92; p=0.001). Women and men were almost equally affected with MDD. Participants who were getting older were more likely to get depressed compared to younger participants. Participants who had perceived social support and positive coping skills were less likely to meet the MINI DSM 5 criteria for Major Depressive Disorder.. The refugee participants with negative coping strategies were more likely to meet the MINI DSM V criteria for Major Depressive Disorder (MDD)

Table 2 below summarizes the frequency of MDD and associated socio-demographic characteristics.

Table 2: Prevalence of MDD and associated Socio-demographic characteristics among the refugees attending the Inter-Aid refugee centre, Kampala, Uganda.

The significant post-migration difficulties associated with MDD amongst the refugees were difficulty in accessing the health and welfare services, difficulty adjusting to the cultural life in Uganda, being discriminated against and worrying about their families who were out of Uganda whom they had left behind in their countries of origin. These post migration difficulties had a negative impact on the mental health and social integration on the refugee populationsComorbid medical illnesses among the study participants

Comorbid chronic medical illnesses were common amongst the refugees. These were assessed using a prepared Medical Illness Questionnaire to which participants responded as either “YES” or “NO” when asked about physical medical illnesses. Fig 1 below summarises these illnesses.

Fig 1: Co-morbid medical illnesses among the refugees

The chronic medical illnesses which were common among the study participants included hypertension as most prevalent, at 107 (28.6%), followed by Diabetes Mellitus, 52 (13.9%), HIV/AIDS 34 (9.1%), TB and cancer each at 6 (1.6%). The other illnesses accounted for 36 (9.6%) and included peptic ulcer disease (PUD), epilepsy, arthritis, cardiac and renal diseases. Though medical diseases were not significantly associated with MDD, accessing healthcare was.

DISCUSSION

This study set out to determine the prevalence of Major Depressive Disorder (MDD) and its associated factors among the adult refugee participants attending Inter- Aid refugee centre in Kampala city, Uganda. The majority of our study participants were females 218 (58%) with the mean age of 37.05 years (SD 12.08%). Most of the refugee populations originated from more than ten African countries with only a few non-African countries such as Yemen and Syria. The Congolese made up the majority (64.7%) followed by Burundi (13.10%). This is probably due to geographical proximity, cultural similarity and use of a common language of communication (Swahili). Around 70% of the study participants had migrated with their family and the major reason for migration was war conflict based on unsettled political crises. Uganda is the leading African country in hosting more than 1.2 million refugee populations. This may be due to Uganda’s hospitable refugee policy and political stability in these past 30 years. (Muhwezi WW and Sam DL, 2004)³

From our study finding, the prevalence of MDD was found to be 46.52% a finding suggesting that MDD was a very common mental health problem among the refugee population compared to the general Ugandan population which is usually stated to be around 6.7% (Ovuga et al., 2017)²⁸ . Other studies in Africa found similar high rates of MDD among Internally Displaced Persons (IDP) Southern Sudan and IDP refugees in Northern Uganda at 49.9 % and 67% respectively (Roberts et al., 2009)²⁹. Feyera et al., 2015)¹⁴ found MDD prevalence of 38.3% % among the Somali refugee population at Melkadida refugee camp in South-Eastern Ethiopia¹⁴. Elsewhere in a Mexican refugee camp, Hynes M and Cardozo DL (2003)¹⁵ found an MDD prevalence of 38.8% among Guatemalan refugees¹⁵. However in other studies conducted among the refugee populations in some European countries; the prevalence of Major Depressive Disorder was much higher than our finding e.g a Norwegian a study conducted among the refugee population found an MDD prevalence of 64% (Teodorescu et al., 2012)⁹. These differences could be due to environmental/cultural factors as refugees in Europe come from very culturally different countries^{38, 39}. The second reason could be also due to the use of different instruments. We used the diagnostic MINI depressive module of DSM 5 criteria ^{19, 20} and yet the other studies used screening tools for depression such as PHQ-9, the SRQ-20 and HSCL-25 among the internally displaced peoples in Southern Sudan, and northern Uganda and Ethiopia respectively ^{21, 22, 32.} Our study used a diagnostic tool, the new version of DSM 5 MINI depressive module^{19, 20} and after a psychological distress screening instrument, the SRQ-20²².

All the psychosocial determinants with significant association on bivariate analysis at p-value ≤ 0.05 were entered into the multivariate analysis to see if these factors were independently associated with Major Depressive Disorder. Our study found that respondents who were elderly were more likely to get depressed compared to younger participants. Age was independently associated with MDD, with ages of over 50 years being strongly associated with MDD. However, in the Ethiopian study among the Somali refugees at Melkadida refugee camp the finding about older age was not statistically significant and not associated with Major Depressive Disorder (Feyera, et al. 2015)¹⁴. The possible explanation for older age and its association with depression in our study was probably due to the decreased social support (no family, friends), financially insecurity, joblessness and physical illnesses such as diabetes, hypertension with reported difficulties in accessing health services.

As regards to gender, we found that females and males were equally affected with Major Depressive Disorder. This contrasted with other studies e.g. the Ethiopian study among the Somali refugees at Melkadida refugee camp where women were twice more likely to get depressed than men (Feyera et al., 2015)¹⁴. This was a similar finding to the Mexican study among Guatemalan refugees (Hynes M and Cardozo BL, 2003)¹⁵. However, in a study conducted in Toronto among Ethiopian immigrants and refugees the women were less likely to get depressed than men (Fenta et al., 2004)³³.

As for employment, refugees residing in rural camps have different living conditions to those in urban settings. Most studies among the refugee populations were conducted in rural areas. We conducted our study among the urban refugee population which were free to work, move and participate in other daily activities as the nationals. Indeed about 20% of our study participants were employed. However their income was generally low and thus not a protective factor to Major Depression Disorder when compared to the unemployed (p-value 0.062)

For family factors, in our study, being divorced was not associated with Major Depressive Disorder which was opposite to other study findings e.g. among the Somali refugee population in Melkadida camp in Ethiopia (Feyera et al., 2015)¹⁴ or among Vietnamese refugees in USA (Buchwald et al., 1993)³⁴. However, our participants who had children or big families were three times more likely to get depressed than those who were single and with no children. This finding was more associated with men who were the household heads and providers for the families.

As for traumatic events, our study finding was that experiencing traumatic events was not singularly independently associated with Major Depressive Disorder. This finding was inconsistent to other refugee study findings e.g. the Somali refugee in Melkadida refugee camp in Ethiopia (Feyera et al., 2015)¹⁴ and the Guatemalan refugee study in a Mexican refugee camp. (Sabin et al, 2003)³⁶. This could be possibly explained by having a more favourable post migration resettlement environment in Kampala which allowed the refugees easy access to mental health services aimed mainly at combatting trauma-related mental illness such as Post traumatic stress disorder (PTSD), anxiety and depression. There was easy access to a psychiatrist, psychologist or social workers at Uganda’s Inter-Aid refugee centre in Kampala.

Our participants who had good perceived social support from their family, friends or other special persons were less likely to get depressed compared to those who had none. This finding was similar to studies conducted among the Ethiopian immigrants /or refugees in Toronto (Fenta et al., 2004)³³ and Vietnamese refugees in USA (Buchwald et al., 1993)³⁴ both of which showed low prevalence rates of MDD. The reason was that refugees in Toronto and USA had bigger numbers of social services with higher psychosocial support from community families, friends and other special persons.

As for coping skills, in our study, refugees who had positive coping skills were less likely to develop Major Depressive Disorder. Positive coping skills were a protective factor from getting depression. While those participants who had negative coping skills were twice more likely to get depressed comparing to those who had none. One study reported that inability to cope with the new adverse life events puts the refugee at increased risk of developing depression (Feller et al., 2001)^35. Discrimination was reported as often stressful in our refugees similar to other studies³⁷.

CONCLUSIONS AND RECOMMENDATIONS

The prevalence of Major Depressive Disorder (MDD) among the urban adult refugee study participants attending Inter-Aid refugee centre in Kampala district was high at 46.52%. These were urban refugees and couldn’t be compared to rural camp refugee populations of other studies. Among the participants, those who were of older age, had low social support, high suicidal risk scores, and who used negative coping skills were more likely to meet criteria for Major Depressive Disorder. However, those who used positive coping skills were less likely to have Major Depressive Disorder as a strong protective factor against MDD.

Based on the results of our study, prevalence of Major Depressive Disorder (MDD) was found to be high among our urban refugee population. We recommend that MDD should be routinely screened for among the refugee populations especially within the urban refugee camps. The practice of routine screening for MDD should be done routinely for early detection and treatment of depression so as to lower the burden of the illness and enhance the quality of life of the refugees and lessen suicide risk. This calls for increasing awareness of mental illness issues and implementing mental health training of staff within the refugee camps in Africa as elsewhere in the world.

REFERENCES

1. Pastore, F. (2005). “The policies for the management of international migrations from the XX to the XXI century. A tale of territorial sovereignties and people on the move. Genus: 347-367.
2. UNDP (2017): Uganda’s contribution to refugee protection and management. https://data2.unhcr.org/en/documents/download/64687
3. Muhwezi, WW and Sam DL(2004): Adaptation of urban refugees in Uganda: A study of their socio-cultural and psychological well-being in Kampala city. Journal of Psychology in Africa 14(1): 37-46.
4. Omata, N. (2012). Refugee livelihoods and the private sector: Ugandan case study, Refugee Studies Centre, Department of International Development, University of Oxford (hiproject@qeh.ox.ac.uk), RSC Working Paper Series No. 86.
5. Nshemerirwe, S., Nasinyama S and Twebaze A. (2013): Prevalence Of Gender Based Violence Among Refugees In Urban Kampala, Uganda. African Journal Of Traumatic Stress, 2013, 3(1): 2-6.
6. Onyut LP, Neuner F, Ertl V, Schauer E, Odenwald M, Elbert T. Trauma, poverty and mental health among Somali and Rwandese refugees living in an African refugee settlement-an epidemiological study. Conflict Health. 2009;3(6):90–107
7. Patil, C. L., et al. (2010). “Forced migration: Complexities in food and health for refugees resettled in the United States. Annals of Anthropological Practice 34(1): 141-160.
8. Teodorescu, D.-S., et al. (2012). Posttraumatic growth, depressive symptoms, posttraumatic stress symptoms, post-migration stressors and quality of life in multi-traumatized psychiatric outpatients with a refugee background in Norway. Health and quality of life outcomes 10(1): 84.
9. Teodorescu, D.‐S., Heir, T., Hauff, E., Wentzel‐Larsen, T. & Lien, L.(2012). Mental health
   problems and post‐migration stress among multi‐traumatized refugees attending outpatient
   clinics upon resettlement to Norway. Scandinavian Journal of Psychology 53, 316–332.
10. Mollica RF, Cardozo BL, Osofsky HJ, Raphael B, Ager A, Salama P (2004): Mental health in complex emergencies. Lancet 364 (9450): 2058-2067. 10.1016/S0140-6736(04)17519-3.
11. Maitland, A (2017): The St Vincent de Paul Society of Australia, ABN 50 748 098 845, Charity Number 23838
12. Connor P. (2012) Balm for The Soul: Immigrant Religion and Emotional Well‐Being . IOM International Migration. https://doi.org/10.1111/j.1468-2435.2010.00623.x
13. Maynard K (2003): Refugees and forced displacement. Healing Communities in Conflict: The United Nations University Collections http://collections.unu.edu/eserv /UNU:2434/nLib9280810863

14. Feyera, F., et al. (2015). “Prevalence of depression and associated factors among Somali refugees at Melkadida camp, southeast Ethiopia: a cross-sectional study.” BMC psychiatry 15(1): 171.
15. Hynes, M. and Cardozo B. L (2000). “Observations from the Centers for Diseases Control(CDC): Sexual violence against refugee women.” Journal of women’s health & gender-based medicine 9(8): 819-823.
16. Peltzer, K. (1999). “Posttraumatic stress symptoms in a population of rural children in South Africa.” Psychological Reports 85(2): 646-650.
17. UNHCR TURA et al. (2016) africacheck.org/spot-check/yes-uganda-hosts-refugees-african-country
18. Kish Leslie: Survey Sampling. John Wiley & Sons, INC Wiley Classics Library Edition Published 1995.
19. Sheehan, D.V., Lecrubier, Y., Sheeham, H.,et al (l998) The Mini-International Neuropsychiatric Interview (M.I.N.I.): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD- 10. Journal of Clinical Psyc-hiatry, 59(suppl20), 22-23.
20. DSM 5, American Psychiatric Association, 2013. Washington DC, USA
21. PHQ-9 Questionnaire for Depression Scoring and Interpretation Guide For physician use only. https://www.med.umich.edu/1info/FHP/practiceguides/depress/score.pdf
22. Nakimuli-Mpungu E, Mojtabai R, Alexandre PK, Katabira E, Musisi S, Nachega JB, Bass JK. Cross-cultural adaptation and validation of the self-reporting questionnaire among HIV+ individuals in a rural ART program in southern Uganda. HIV/AIDS (Auckland, NZ). 2012; 4:51
23. Granello DH (2010): The Process of Suicide Risk Assessment: Twelve Core Principles. Journal of counseling and development: JCD 88(3) · DOI: 10.1002/j.1556-6678.2010.tb00034.x
24. Zimet G, Dahlem NW, Zimet SG, Farley GK (1988): The Multidimensional Scale of Perceived Social Support. Journal of Personality Assessment 52(1):30-41· DOI: 10.1207/s15327752jpa5201_2
25. Nakigudde J, Musisi S, Airaksinen E., Enhval A., Agren H. (2009): Adaptation Of The Multidimensional Scale Of Perceived Social Support In A Ugandan Setting. African Health Sciences,Aug 2009, 1(9) Suppl 1:S35-41.
26. Carver C, Scheier M and Weintraub JK (1989). Assessing Coping Strategies: A Theoretically Based Approach. Journal of Personality and Social Psychology 56(2):267-83 ·DOI: 10.1037//0022-3514.56.2.267.

27. Aragona M, Pucci D, Mazzetti M, Geraci S (2012): Post-Migration Living Difficulties As A Significant Risk Factor For PTSD In Immigrants: A Primary Care Study. Italian Jo u r n a l Of P u b l i c He a l t h, IJPH – 2012, 9(3) doi: 10.2427/7525
28. Ovuga E, Boardman J and Wasserman D (2005).The prevalence of depression in two districts of Uganda. Social Psychiatry and Psychiatric Epidemiology 40(6):439-445 · July 2005 DOI: 10.1007/s00127-005-0915-0
29. Roberts B, Ocaka KF, Browne J, Oyok TO, and E Sondorp E (2008) Factors associated with the health status of internally displaced persons in northern Uganda. J Epidemiol Community Health. 63(3): 227–232.doi: 10.1136/jech.2008.076356
30. Roberts B, Ocaka KF, Browne J, Oyok T, Sondorp E (2008). Factors associated with post-traumatic stress disorder and depression amongst internally displaced persons in northern Uganda. BMC Psychiatry. 2008 Dec; 8(1):38.
31. Kirmayer, L. J., et al. (2011). “Common mental health problems in immigrants and refugees: general approach in primary care.” Canadian Medical Association Journal 183(12): E959-E967.
32. Haroz EE, Bolton P, Gross A, Chan KS (2016): Depression symptoms across cultures: an IRT analysis of standard depression symptoms using data from eight countries.  Social Psychiatry and Psychiatric Epidemiology 51(7) DOI: 10.1007/s00127-016-1218-3
33. Fenta H, Hyman I and Noh S.(2004): Determinants of depression among Ethiopian immigrants and refugees in Toronto. J Nerv Ment Dis.2004 May;192(5):363-72. DOI:10.1097/01.nmd.0000126729.08179.07
34. Buchwald D, Manson S, Dinges N and Keane EM (1993): Prevalence of depressive symptoms among established Vietnamese refugee in United States.  Journal of General Internal Medicine 8(2):76-81 · DOI: 10.1007/BF02599987 ·
35. Feller, E. (2001): The Evolution of the International Refugee Protection Regime, 5 Wash. University of Washington Journal of Law and Policy 5 (129). https://openscholarship.wustl.edu/law_journal_law_policy/vol5/iss1/11
36. Sabin, M., et al. (2003). “Factors associated with poor mental health among Guatemalan refugees living in Mexico 20 years after civil conflict.” JAMA 290(5): 635-642.
37. Ellis BH, MacDonald HZ, Lincoln AK, Cabral HJ. Mental health of Somali adolescent refugees: The role of trauma, stress, and perceived discrimination. Journal of Consulting and Clinical Psychology. 2008;76:184–193.Fazel, M., et al. (2005). “Prevalence of serious mental disorder in 7000 refugees resettled in western countries: a systematic review.” The Lancet 365(9467): 1309-1314.
38. Fazel, M., et al. (2005). “Prevalence of serious mental disorder in 7000 refugees resettled in western countries: a systematic review.” The Lancet 365(9467): 1309-1314.
39. Lindert, J., et al. (2008). Mental health, health care utilisation of migrants in Europe. European Psychiatry 23: 14-20.