Common symptoms of depression among patients with depressive disorders receiving outpatient care in tertiary hospitals in Addis Ababa, Ethiopia: A cross-sectional study

Common symptoms of depression among patients with depressive disorders receiving outpatient care in tertiary hospitals in Addis Ababa, Ethiopia: A cross-sectional study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Common symptoms of depression among patients with depressive disorders receiving outpatient care in tertiary hospitals in Addis Ababa, Ethiopia: A cross-sectional study Eyerusalem Solomon, Nardos Seifu, Girmay Medhin, Barkot Milkias This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7495304/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background- While DSM-5 criteria for Depressive Disorders focuses on affective and cognitive symptoms, research in Ethiopia indicates that distress is commonly expressed through physical and culturally specific symptoms, reflecting differences in symptom expression across settings. In practice, screening tools and clinical interviews incorporate symptoms not included in DSM-5. We aimed to identify the common presentations and symptom domains of depressive disorders (somatic, cognitive, affective, and other) and examine their association with socio-demographic factors among outpatients in Ethiopia. Methods- We conducted a facility-based cross-sectional study at three tertiary hospitals in Addis Ababa, Ethiopia. Consecutive sampling was employed to include 165 adult patients who received outpatient care for depressive disorders at one of the three hospitals within the last two years. We collected data through a questionnaire designed for extracting sociodemographic and clinical factors from clinical records and face-to-face interviews. We used the validated Amharic versions of PHQ-9 and PHQ-15 with additional symptoms identified as locally relevant idioms of distress to identify depressive symptoms. We analyzed the data using SPSS version 26 and employed descriptive statistical methods to summarize the data. Cross-tabulation was done to examine associations between sociodemographic and clinical characteristics and symptom domains. Results- Feeling down, depressed or hopeless was the most frequently endorsed symptom (90.3%) of depression. Nearly all participants endorsed the “Somatic symptoms” domain (98.8%), followed by “Affective symptoms” (96.4%), and “Other symptoms” (93.3%) domains — which include local idioms of distress — while only 78.2% endorsed symptoms in the “Cognitive symptoms” domain. Among participants who responded to the most distressing symptom question, sleep problems were reported as the most distressing symptoms, while most of the reported symptoms, 58(35.2%), belonged to the “Affective symptoms” domain. Conclusions- Our study highlighted that patients seeking care for depressive disorders experience distress in ways that are not fully captured by routinely used diagnostic criteria such as the DSM-5. This calls for further research to understand broader clinical presentation of depressive disorders in Ethiopia, that would inform contextually sensitive and patient- centered approaches to diagnosis and treatment. This would ensure that even less commonly reported but highly distressing symptoms receive adequate attention in clinical care. Depression Detection Domains of depression Symptoms of depression Ethiopia Figures Figure 1 Figure 2 Figure 3 Background Depressive disorders are characterized by persistent feelings of sadness and loss of interest along with other symptoms leading to impairment in functioning (1,2). Global estimates for the lifetime prevalence of major depression ranges from 14 to 17%, with one-year prevalence estimates between 4 to 8%. Major depressive disorder (MDD) has a lifetime prevalence of 10-25% in women and 5-12% in men (3). From the 2003 Ethiopian National Health Survey, which included 9 regions, the one-year prevalence of depressive episodes was found to be 9.1% (4) and accounted for around 6.5% of the disease burden, exceeding the contribution of major infectious diseases (3). It is unarguable that MDD qualifies as a clinical syndrome. DSM 5 outlines the core symptoms (sadness and loss of interest) and a range of associated depressive symptoms (5). These include changes in weight or appetite, changes in sleep pattern, psychomotor retardation or agitation, fatigue, worthlessness or guilt, impaired concentration or indecisiveness and suicidal thoughts or behaviors (6), which can broadly be classified into affective, somatic and cognitive domains (7,8). While the DSM-5 relies on the nine criterion symptoms for MDD, common rating scales comprise multiple items which are not part of the DSM criteria (9). For instance, the Beck Depression Inventory (BDI)(10) includes irritability, pessimism, and feelings of being punished; the Hamilton Rating Scale for Depression (HRSD) (11) covers anxiety, sexual dysfunctions, hypochondriasis, and insights into the depressive illness; and the Center for Epidemiological Studies Depression Scale (CESD)(12) includes frequent crying, talking less, and perceiving others as unfriendly. This inconsistency implies a lack of consensus regarding the construct and measurement of depression (9). Hence, worldwide use of DSM criteria to diagnose depression does not imply that diverse populations’ clinical presentations are globally similar (13); and commonly used tools may not be fully representative of the diverse depressive symptomatology around the world. Although the core symptoms of depression, as outlined in the DSM, are widely recognized, MDD has inarguably heterogenous clinical presentation varying across individuals and settings (14). Several studies have reported major differences in symptom clustering and severity among different populations (14,15). In a validation study of brief depression questionnaires conducted in Ethiopia that recruited 306 participants, 5.9 % were diagnosed with MDD using a culturally adopted version of Mini-International Neuropsychiatric Interview (MINI) (2). In this study, cases reported having irritability more commonly than the two core symptoms of DSM, suggesting the need to consider irritability as a core symptom of depression. In addition, somatic symptoms, which were given less emphasis on DSM, were the most commonly endorsed symptoms in this study (16). This heterogeneity in clinical presentation may be influenced by various factors, including biological determinants such as genetic variations (17,18), psychological and sociocultural differences such as varying attitudes, beliefs, and stigma. This influences how people experience, interpret, perceive, and seek medical help for depressive symptoms (19,20) posing significant challenges in the recognition and detection of depression by health care providers. Alarmingly low detection rates of depressive disorders by primary care providers have been reported from low-and-middle-income-countries (LMICs) (21), including Ethiopia (22). A qualitative study conducted in rural Ethiopia that shed a light on the understandings of depression among community members and primary care attendees highlighted that cultural beliefs and explanatory models shape how symptoms are understood, reported and recognized by health care providers (20). In this study, non-DSM somatic and emotional symptoms of depression were commonly reported by patients and were identified as local idioms of distress (20). In Ethiopia, clinical practice and research on depression has heavily relied on the recognition of DSM symptoms such as sadness, anhedonia, and sleep disturbances. Although some studies (2,22) have identified somatic symptoms and irritability as common manifestations of depression, there remains a lack of evidence on the broader presentations outside of DSM that include locally relevant idioms of distress in Ethiopian clinical settings. Beyond the symptom count, little is understood about the syndromic presentation in clinical settings, and which domains, such as affective, somatic or cognitive, are predominantly perceived as most distressing by patients. Understanding these nuances aligns with recent efforts to improve the detection of depression in primary care by refining detection strategies and tailoring treatment approaches to be more contextually relevant (23). Building on such initiatives, our study aimed to identify the common and most distressing presentations and domains of depressive symptoms; and to explore the association between socio-demographic factors and the symptom domains among patients who are receiving outpatient care for depressive disorders in tertiary hospitals in Addis Ababa, Ethiopia. Methods Study setting, design and study period: We recruited study participants from outpatient departments of psychiatry at Tikur Anbessa Specialized Hospital (TASH), Zewditu Memorial Hospital (ZMH), and Yekatit -12 Hospital. The three hospitals are tertiary hospitals located in the capital city of Ethiopia. The hospitals run psychiatric outpatient services which are given in collaboration with the Department of Psychiatry, College of Health Sciences, Addis Ababa University. We used health facility based cross sectional study design and the data collection was conducted from June 2021 until September 2021. Sample size and recruitment of study participants : We estimated a sample size of 165 with the following assumptions: assumed depression prevalence of 11% based on a previous study (24), 5% margin of error, 95% confidence in the estimate, and 10% non-response rate. The source population was all patients who have been receiving psychiatric outpatient care at one of the three hospitals within the past two years from the time of data. The inclusion criteria were – being over 18 years of age, having received a diagnosis of Major depressive disorder or Persistent Depressive Disorder by a psychiatry resident or a psychiatrist. The diagnosis should have been newly made in the past one year, or if it was made over a year ago, the patient must not have been in remission during the study period. In addition, the participants must have been able to communicate in Amharic and be able to give informed consent. Patients who had other comorbid mental health or medical conditions, had a diagnosis of depressive disorder that was made over one year ago and were in remission during the study period, those who had communication barriers, or were acutely disturbed or distressed during data collection were not eligible for the study. Data collection tools and data collection approaches: We collected data through a questionnaire designed for extracting sociodemographic and clinical factors from clinical charts. This included age, sex, address, educational status, marital status, religion, occupation, economic status, chief complaint of the patient, duration of illness, initial diagnosis, most distressing symptoms, start of treatment and types of treatment they are involved in. Additionally, we conducted face-to-face interviews using the Amharic version of Patient Health Questionnaire (PHQ-9) and PHQ-15. The PHQ-9 is a widely used depression screening scale globally (25). It consists of 9 items that follow DSM 5 and it has been validated and extensively used locally (25). The PHQ-15 is a 15 items screening instrument that has been used as a tool in several local studies to screen for somatic symptoms and has demonstrated high reliability and validity among the Ethiopian population (26). For the purpose of this study we added one item, “burning sensation in the head”, to the PHQ- 15, which is a local somatic idiom commonly identified in the Ethiopian settings (27,28). We omitted two items, namely, trouble sleeping and fatigue, from PHQ 15 as they are items included in the PHQ 9. Similarly, we supplemented the PHQ-9 with three items: irritability, noise intolerance and urge to shout/disappear/run which have been identified as common local idioms of distress (20,29). The recruitment process involved selecting eligible participants consecutively, starting from the most recently recorded ones, until the planned sample size was attained. Data was collected at the three hospitals by psychiatry residents who were trained at the beginning of the study. Operational definitions All the 26 items were categorized into four main symptom domains, “Affective symptoms”, “Somatic symptoms”, “Cognitive symptoms” and “Other symptoms”, based on evidence from literature (30, 31, 32, 33,34,20) including meta-analysis of factor- analytic studies (35) and expert consensus. “Affective symptoms” – refer to the changes in the patient’s emotional state. Items in this domain include - little interest or pleasure in doing things, feeling down, depressed or hopeless and irritability (32). “Somatic symptoms” – refer to bodily experiences or physical complaints of patients. Items in this domain include - tired/ low energy, sleep problem, appetite problem, stomach pain, back pain, pain in your arms, legs, or joints (knees, hips, etc), headaches, burning sensation in the head, chest pain, dizziness, fainting spells, feeling your heart pound or race, shortness of breath, pain or problems during sexual intercourse, constipation, loose bowels, or diarrhea, nausea, gas, or indigestion, menstrual cramps or other problems with your periods [Women only] (33). “Cognitive symptoms” – refer to changes in mental processes and negative thoughts or beliefs. Items in this domain include - feeling bad about self, suicidal thoughts and trouble concentrating (34). “Other symptoms” – refer to behavioral, perceptual or culturally specific expressions of distress that do not fit well in the other domains. These include psychomotor agitation/ retardation, noise intolerance and urge to disappear/ run/shout (20). Data analysis We conducted data entry, cleaning and analysis using SPSS version 26. Descriptive summary was used to understand the data and cross tabulations with measures of associations were used to investigate association of depressive disorder symptoms with sociodemographic and clinical factors. Results Background characteristics of the study participants Sociodemographic characteristics A total of 165 study participants were recruited from the study sites and all were successfully interviewed, making a response rate of 100%. The age ranged from 18 to 66, with the largest proportion, 48.5% (n=80), being in the age range of 20 to 40 years. The majority, 62.4% (n=103), were females, 42.4% (n=70) were single, 54.5% (n=90) were employed, 85.5% (n=141) were residents of Addis Ababa, and 90.9% (n=150) had some formal education. (see Table -1) Clinical Characteristics In 92.7% (n= 153) of the participants, the clinical diagnosis was MDD, of whom 2.6% (n=4) were specified to have anxious distress. Those with a diagnosis of PDD were 6.7% (n=11), while only one participant had a diagnosis of both PDD and MDD. The mean duration of treatment was 3.6 years. Newly diagnosed study participants who had not yet started treatment were 13.3% (n=22) and these had the shortest duration of follow-up. From all the study participants, the longest duration of treatment was 18 years; 47.3% (n=78) reported receiving both psychotherapeutic and pharmacological care, while 43% (n=71) received pharmacotherapy only and 9.7% (n=16) received psychotherapy only. Feeling down, depressed or hopeless was endorsed in 90.3% (n= 149), making it the most frequently endorsed symptom, while fainting spells was the least reported, 10.9% (n=18), symptom. Eleven out of the total of 26 items were endorsed by most of the study participants, including the two items that were added as locally common idioms of distress- noise intolerance 77% (n=127) and irritability 72.7% (n=120). Figure 1 presents the symptom profile of 165 study participants with depression. Sleep problems was the most commonly reported symptom as being the most distressing symptom followed by having a depressed mood . Almost all, the study participants endorsed having experienced at least one symptom from the “Somatic”, “Affective” and “Other symptoms” domains, 98.8%, 96.4% and 93.3% respectively, while only 78% reported having cognitive difficulties (Figure 2). A significant association was found between the educational level and religious status of study participants with the endorsement of symptoms from the “Other symptoms” domain. Most of those whose educational level was at elementary and higher level of education endorsed symptoms from the “Other symptoms” domain (P-value of 0.006) as shown in Table 2 . Newly diagnosed patients were found to have significantly higher endorsement of cognitive symptoms than those who were on follow up (P-value of 0.049)/ See Table 3 . There was no statistically significant association between clinical and sociodemographic characteristics and endorsing symptoms in the “Affective symptoms” and “Somatic symptoms” domains of depression. Among participants who reported their most distressing symptoms (n=138), symptoms in the “Affective symptoms” domain were the most frequently endorsed, reported by 58(42.03%) participants, while those in the “Other symptoms” domain were the least frequently endorsed, reported by just 1(0.73%) participant. See Figure 3. Discussion We conducted this study in tertiary hospitals in Addis Ababa with the aim of exploring the common symptom presentations of patients receiving outpatient care for depressive disorders. To the best of our knowledge, this is the first study that explored the common symptoms and syndromic profile of depressive disorders, beyond the commonly utilized diagnostic tools, in an urban clinical context of Ethiopia. Our study yielded the following key findings; first, the most commonly reported depressive symptoms were feeling down, depressed, or hopeless , while fainting spells were the least common. Second, among symptom domains, somatic symptoms were the most commonly reported symptoms with 98.8% of all participants endorsing at least one somatic symptom, closely followed by affective and other symptoms, while cognitive symptoms were the least reported symptoms. Third, among individual symptoms, sleep problems were reported as the most distressing , whereas the “Affective symptoms” domain was the most frequently reported most distressing domain. Fourth, a significant association was found between the educational level of participants and endorsing symptoms in the "Other symptoms" domain, while clinical status (New vs Follow up patient) showed significant association with the endorsement of symptoms in the “Cognitive symptoms” domain. The DSM lists “persistently depressed mood” as one of the two required core symptoms for the clinical diagnosis of MDD ( 5 ). Our findings of sadness and hopelessness as the most frequently reported symptoms also demonstrate that such emotional symptoms are cardinal features of depressive disorders. This is in line with previous cross-cultural studies( 36 , 37 ) that show that “feeling sad, low or hopeless” are nearly universal symptoms of depression, including in LMICs like Ethiopia ( 38 ). However, our findings might be expected given that participants were recruited from a clinical setting where the DSM criteria is used for diagnoses. Although it is not one of the two core symptoms, our study found fatigue as the second most reported symptom (81.8%) of depression. This is in agreement with studies across various settings that have recognized fatigue as the most prevalent (up to 95%) and often underappreciated symptom of depression ( 32 , 39 – 41 ). Except for the “Cognitive Symptoms” domain, which showed the lowest frequency, all domains generally had comparable frequency of reporting with “Somatic symptoms”, which had the highest frequency. This is in line with studies conducted in LMICs, including Ethiopia, that have consistently reported that somatic challenges were often expressed alongside emotional symptoms in depressive presentations ( 36 ). In this study, almost all of the participants reported experiencing somatic symptoms in combination with affective and other symptoms. In addition, our study found that sleep problems were the most frequently reported most distressing symptoms. Our findings are in line with studies that have explained that sleep problems are not only common but also reflect a neurobiological disruption making them one of the core and pervasive symptoms of depression ( 42 , 43 ). They can be drivers of mood worsening and points of suffering with significant impact on quality of life( 44 – 46 ) and risk of suicide( 47 ). They are shown to frequently lead to active help-seeking demonstrating the degree of distress and burden associated with it. Somatic symptoms have been widely recognized as one of the culture-specific expressions of distress that carry unique meaning but can be easily misinterpreted and misdiagnosed ( 48 ). As an example, this was demonstrated in a study which compared Chinese and Australian Caucasian patients, where the majority of Malaysian Chinese reported somatic symptoms, and only a small proportion of Australian Caucasians reported these symptoms ( 19 ).This shows that culture, illness perception, stigma and health- care seeking norms shape the expression and presentation of symptoms of depression ( 19 , 49 , 50 ). In addition, the high co-morbidity between physical illness and depression ( 51 , 52 ), coupled with the tendency of patients with medical conditions to express psychological distress through physical symptoms ( 19 ), all reinforce the dominance of somatic symptoms. The co-morbid medical illnesses might necessitate diagnosis and treatment by their own right. The weight that culture bears on the experience and expression of distress in Ethiopia is also reflected in the proportion of patents who endorsed the locally identified idioms of distress, such as, irritability (72.7%) and noise intolerance (77%). Although irritability does not appear in standard diagnostic frameworks for adult depressive disorders, studies indicate that over 50% of adults with MDD report having it ( 53 ). Studies across LMICs, including Ethiopia, confirm that locally salient symptoms, such as irritability, noise intolerance and somatic pain, frequently emerge in primary care settings but are rarely detected as they do not match diagnostic categories. In a study that aimed to improve detection of depression in PHC settings in rural Ethiopia, a four-item screening tool, that included irritability and noise intolerance, in addition to the core symptoms of depression, was pilot tested ( 29 ). This tool outperformed the two-item tool with core symptoms alone in detecting depression, highlighting the clinical relevance of the additional symptoms. In our study, although the “Cognitive Symptoms” domain showed the lowest frequency of reporting (78.2%) as a domain, comparison with previous studies warrants caution. Previous studies conducted in Ethiopia have reported lower prevalence rates, up to 54% ( 54 , 55 ), similar to a recent systematic review and meta-analysis that found pooled prevalence of cognitive impartment in MDD to be 53% (95% CI: 41–64%) ( 56 ). Our finding of higher frequency of cognitive symptom reporting is likely due to the classification of symptoms such as feeling bad about self and suicidal thoughts in this domain, and our reliance on self- report of the symptoms as opposed to using standard tools to measure cognitive deficits. Comparison with previous findings was difficult due to the lack of PhQ-9 item level data among patients with depressive disorders from similar settings. Our analyses also demonstrated that the endorsement of cognitive symptoms was significantly associated with having a newly diagnosed and untreated depressive disorder. This also needs similar caution in interpretation as above. However, this finding corroborates previous studies that have established that cognitive impairments and suicidal thoughts - in the same category in our study- are associated with acute and untreated phases of depression in addition to illness severity ( 55 , 57 – 59 ). In Summary, we found that the core symptoms of depression were among the most frequently endorsed individual symptoms, while somatic symptoms had the highest frequency of reporting as a domain, closely followed by the other two symptom domains. This was coupled with findings of a somatic symptom, sleep problem, as the most frequently reported most distressing individual symptom, while affective symptoms were the most reported most distressing symptoms as a domain. This shows that diagnosis will remain inaccurate without proper enquiry of both affective and somatic symptoms highlighting the need to incorporate the commonly endorsed somatic symptoms in diagnostic tools, while paying attention to locally recognized expressions of distress ( 60 ). However, further studies are needed to determine the specific symptoms and weight that they should carry in the diagnosis of depressive disorders in settings like ours. Our study has a few limitations that require consideration. First, due to its cross-sectional nature, causal inferences can be limited. Second, reports of the most distressing symptoms may have been subject to bias by respondents’ current clinical presentation, as some had been in care for up to two years and may have been responding to treatment. Third, cognitive and physical symptoms were assessed using self-report and medical records alone, without objective measures. Cognitive symptoms were captured with only two PHQ-9 items, which may underestimate their prevalence, indicating the need for more comprehensive assessment tools in future research. Conclusion Our study demonstrated that patients seeking care for depressive disorders in the urban context of Ethiopia had symptom presentations that were dispersed across domains, including culturally prevalent expressions of distress merging as prominent. This reveals that peculiarities in social, cultural and religious contexts have impacts on emotional expression; and depressive symptoms may manifest in ways that diverge from conventional diagnostic tools. Our findings highlight the need for clinicians to look beyond core affective symptoms and attend to all domains of distress, avoiding narrow diagnostic checklist. Treatment approaches that address the full spectrum of symptomatology, including the local idioms of distress, should be adapted. In addition, individualized approaches should be tailored to focus on symptoms that cause significant suffering. This calls for the development and validation of brief, culturally informed screening instruments that integrate both commonly endorsed and severely distressing symptoms, as well as prospective studies that capture evolving symptom profiles over time. Fundamentally, progress towards a more holistic and context-sensitive clinical and research approaches could narrow the gap between global diagnostic frameworks and the lived experiences of patients in settings like ours. Abbreviations AA- Addis Ababa BDI-Beck depression inventory CDC- Centers for disease control CESD- Center for epidemiological study of depression scale DSM- Diagnostic statistical manual HAMD-Hamilton depression rating scale LAMIC- Low- and middle-income countries PDD- Persistent depressive disorder PHQ- Patient health questionnaire SRQ- Self reporting questionnaire SSI- Somatic symptoms inventory TASH- Tikur Anbessa specialized hospital USA- United States of America ZMH- Zewditu Memorial Hospital Declarations Ethics approval and consent to participate Ethical permission was sought from the Research Ethics Committee of Department of Psychiatry, College of Health Sciences, and Addis Ababa University (Ethical Clearance Ref. No: MF/PSY/167/13 and MF/PSY/168/13). Approval was also sought from each of the hospitals where the data was collected. The study was conducted in accordance with the Declaration of Helsinki. When patients that required intervention (e.g. mismanagement, risks of self-harm, non-adherence) were identified, they were linked with treating psychiatrists working at the specific hospitals. Consent to Participate Before enrollment into the study, the purpose of the study was briefly explained to all participants and informed consent was sought. The filled questionnaires were kept anonymous and confidential. Consent for publication Not applicable. Availability of data and materials The datasets used during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding The study was funded by Addis Ababa University as part of a research study conducted to fulfill requirements for a Certificate in Psychiatry for ES. Authors' contributions ES and BM conceived and designed the study. ES and BM reviewed the literature; ES, BM and GM wrote the original draft. 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Pandi-Perumal SR, Monti JM, Burman D, Karthikeyan R, BaHammam AS, Spence DW, et al. Clarifying the role of sleep in depression: A narrative review. Vol. 291, Psychiatry Research. 2020. Lovato N, Gradisar M. A meta-analysis and model of the relationship between sleep and depression in adolescents: Recommendations for future research and clinical practice. Vol. 18, Sleep Medicine Reviews. 2014. Nutt DJ, Wilson S, Paterson L. Sleep disorders as core symptoms of depression. Dialogues Clin Neurosci. 2008;10(3). Goodman ML, Lee M, Springer A, Schick V, Vaughan E, Markham C, et al. Sleep disturbance as a precursor to anxiety, depression, and PTSD among rural Kenyans: A cross-lagged panel analysis from a rural Kenyan interventional cohort. J Sleep Res. 2024;33(4). Gelaye B, Okeiga J, Ayantoye I, Berhane HY, Berhane Y, Williams MA. Association of suicidal ideation with poor sleep quality among Ethiopian adults. Sleep Breath. 2016 Dec;20(4):1319–26. Kirmayer LJ, Nutt, Lecrubier, Lepine, Davidson. Cultural variations in the clinical presentation of depression and anxiety: Implications for diagnosis and treatment. Vol. 62, Journal of Clinical Psychiatry. 2001. Al Busaidi ZQ. The concept of somatisation: A cross-cultural perspective. Vol. 10, Sultan Qaboos University Medical Journal. 2010. Simon GE, VonKorff M, Piccinelli M, Fullerton C, Ormel J. An International Study of the Relation between Somatic Symptoms and Depression. New England Journal of Medicine. 1999;341(18). Daré LO, Bruand PE, Gérard D, Marin B, Lameyre V, Boumédiène F, et al. Co-morbidities of mental disorders and chronic physical diseases in developing and emerging countries: A meta-analysis. BMC Public Health. 2019;19(1). Borie YA, Tamiso A, Gutema K, Jisso M, Deribe B, Fikre R, et al. Psychological distress and its associated factors among people with specific chronic conditions (diabetes and/or hypertension) in the Sidama region of southern Ethiopia: A cross-sectional study. PLoS One. 2024;19(7):e0303196. Fava M, Hwang I, Rush AJ, Sampson N, Walters EE, Kessler RC. The importance of irritability as a symptom of major depressive disorder: results from the National Comorbidity Survey Replication. Mol Psychiatry. 2010 Aug;15(8):856–67. Ambaw A, Desalegn GT. Magnitude and correlates of cognitive impairment among major depressive disorder patients in Addis Ababa: Institution based cross-sectional study. BMC Res Notes. 2019;12(1). Mekuriaw BY, Wondmu H, Asfaw M, Kassaw C, Molla A. Cognitive impairment and associated factors among patients with mood disorders receiving care at public hospitals in Gedeo zone, Southern Ethiopia. Soc Psychiatry Psychiatr Epidemiol. 2025 May 29; Moges AM. 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Tables Table 1: Background characteristics of study participants Participant Characteristics Frequency N=165 Percent (%) Age in years Below 20 7 4.2 20 to 40 80 48.5 40 to 60 70 42.4 Above 60 8 4.8 Gender Male 62 37.6 Female 103 62.4 Place of residence Addis Ababa 141 85.5 Out of Addis Ababa 24 14.5 Marital status Single 70 42.4 Married 64 38.8 Divorced/Separated 6 3.6 Widowed/Widower 25 15.2 Occupation Employed 90 54.5 Unemployed 25 15.2 Housewife 24 14.5 Student 16 9.7 Missing 10 6.1 Religion Muslim 24 14.5 Orthodox Christian 116 70.3 Protestant Christian 23 13.9 Other 2 1.2 Level of formal education None 15 9.1 Elementary 30 18.2 High school 54 32.7 Higher level Education 66 40.0 Table 2: Association of the “Other symptoms” domain of depression with sociodemographic characteristics Characteristics “Other symptoms” domain P-value Total N=165 Yes n (%) No n (%) Age 0.543 Below 20 7 7 (100.0) 0 20-40 80 76(95.0) 4(5.0) 40-60 70 64(91.4) 6(8.6) Above 60 8 7(87.5) 1(12.5) Sex 0.334 Male 62 56(90.3) 6(9.7) Female 103 98(95.1) 5(4.9) Residence 0.202 Addis Ababa 141 133(94.3) 8(5.7) Out of Addis Ababa 24 21(87.5) 3(12.5) Level of Education 0.006 No 15 13(86.7) 2(13.3) Elementary 30 30(100.0) 0 High school 54 46(85.2) 8(14.8) Higher level education 66 65(98.5) 1(1.5) Occupation 0.392 Employed 90 89(95.7) 4(4.3) Unemployed 25 26(92.9) 2(7.1) Housewife 24 22(91.7) 2(8.3) Students 16 14(87.5) 2(12.5) Marital Status 0.170 Single 70 65(92.9) 1(7.1) Married 64 62(96.9) 2(3.1) Widowed 25 21(84.0) 4(16.0) Divorced / separated 6 6(100.0) 0 Religion 0.027 Muslim 24 19(79.2) 5(20.8) Orthodox Christian 116 110(94.8) 6(5.2) Protestant 23 23(100) 0 Other 2 2(100) 0 Clinical status 1.000 New 22 21(95.5) 1(4.5) Follow up 143 133(93.0) 10(7.0) Table 3: Association of "Cognitive symptoms” domain of depression with sociodemographic characteristics Characteristics Cognitive symptoms domain P-value Total N=165 Yes n (%) No n (%) Age 0.370 Below 20 7 7(100.0) 0 20-40 80 64(80.0) 16(20.0) 40-60 70 51(72.9) 19(27.1) Above 60 8 7(87.5) 1(12.5) Sex 0.339 Male 62 46(74.2) 16(25.8) Female 103 83(80.6) 20(19.4) Residence 0.430 Addis Ababa 141 111(78.7) 30(21.3) Out of Addis Ababa 24 18(75.0) 6(25.0) Level of Education 0.061 No formal education 15 11(73.3) 4(26.7) Elementary 30 26(86.7) 4(13.3) High school 54 36(66.7) 18(33.3) Higher level education 66 56(84.8) 10(15.2) Occupation 0.391 Employed 90 72(77.4) 21(22.6) Unemployed 25 20(71.4) 8(28.6) House wife 24 19(79.2) 5(20.8) Students 16 15(93.8) 1(6.2) Marital Status 0.525 Single 70 58(82.9) 12(17.1) Married 64 48(75.0) 16(25.0) Widowed 25 19(76.0) 6(24.0) Divorced / separated 6 4(66.7) 2(33.3) Religion 0.123 Muslim 24 15(62.5) 9(37.5) Orthodox Christian 116 91(78.4) 25(21.6) Protestant 23 21(91.3) 2(8.7) Other 2 2(100.0) 0 Clinical status 0.049 New 22 21(95.5) 1(4.5) Follow up 143 108(75.5) 35(24.5) Additional Declarations No competing interests reported. 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University","correspondingAuthor":false,"prefix":"","firstName":"Nardos","middleName":"","lastName":"Seifu","suffix":""},{"id":529086627,"identity":"3368ba65-cf17-4f77-a789-b1213639af66","order_by":2,"name":"Girmay Medhin","email":"","orcid":"","institution":"Aklilu Lemma Institute of Pathobiology, Addis Ababa University","correspondingAuthor":false,"prefix":"","firstName":"Girmay","middleName":"","lastName":"Medhin","suffix":""},{"id":529086628,"identity":"21167eaf-4b5f-48b2-adc4-d526112483e0","order_by":3,"name":"Barkot Milkias","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDElEQVRIiWNgGAWjYBACAwYGZjCDjZ2N4QADgw1EmIeglgSgFmawljSEFlza4FoYgFqA4DBhLebsZx8bfPzBEM3HzJZ44Mef8/L8MxIYH7xtY5Czx6HFsifdOHFGAkNuGzPbgYO9bbcNZ9xIYDac28ZgjNNhB9KYD/OAtbA3HOBtuM3YcCOBTZq3jSGxB5eW888QWg7++XPOfv6NBPbfQC31OLXcSGNO5oE67DAP24HEDUBbmIFaEnA5zHLGM2bDGWkSIC0Jh2XbkpM3nnnYLDnnnIRhzwEcIcafxizxwcYmd357m/HHN3/sbOcdTz744U2ZjTx7Aw5rIEACmcPYgC4yCkbBKBgFo4BEAADdJlWN/IPmUwAAAABJRU5ErkJggg==","orcid":"","institution":"Addis Ababa University","correspondingAuthor":true,"prefix":"","firstName":"Barkot","middleName":"","lastName":"Milkias","suffix":""}],"badges":[],"createdAt":"2025-08-30 12:38:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7495304/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7495304/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":93612305,"identity":"4036a4d4-1a28-47b9-a2d8-641b9bbc153a","added_by":"auto","created_at":"2025-10-15 16:17:34","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":110977,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eProportion of participants(N=165) endorsing depressive symptoms from the PHQ-9, PHQ-15 and local idioms.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7495304/v1/7e02796e25edf1a92128d464.png"},{"id":93612303,"identity":"fc68b916-b7f2-44d4-94ae-00e826d6feef","added_by":"auto","created_at":"2025-10-15 16:17:34","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":23361,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eProportion of participants (N = 165) endorsing at least one depressive symptom within each domain.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7495304/v1/1f1cfe8cd1f5aba03c42005c.png"},{"id":93612304,"identity":"ff2d054c-ac49-4f0f-8a55-11e5dbeee156","added_by":"auto","created_at":"2025-10-15 16:17:34","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":15111,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eProportion of participants endorsing \u003c/strong\u003e\u003cem\u003e\u003cstrong\u003emost distressing \u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003esymptoms (n= 138) within each depressive symptom domain.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7495304/v1/a4b9e79b46d19f600f9de123.png"},{"id":93613285,"identity":"783bc03b-c13d-4979-b7b5-d299370cbf1a","added_by":"auto","created_at":"2025-10-15 16:25:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1504147,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7495304/v1/fe464796-c9f8-4ecc-bf83-65caaa85e390.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Common symptoms of depression among patients with depressive disorders receiving outpatient care in tertiary hospitals in Addis Ababa, Ethiopia: A cross-sectional study","fulltext":[{"header":"Background","content":"\u003cp\u003eDepressive disorders are characterized by persistent feelings of sadness and loss of interest along with other symptoms leading to impairment in functioning (1,2). Global estimates for the lifetime prevalence of major depression ranges from 14 to 17%, with one-year prevalence estimates between 4 to 8%. Major depressive disorder (MDD) has a lifetime prevalence of 10-25% in women and 5-12% in men (3). From the 2003 Ethiopian National Health Survey, which included 9 regions, the one-year prevalence of depressive episodes was found to be 9.1% (4) and accounted for around 6.5% of the disease burden, exceeding the contribution of major infectious diseases (3).\u003c/p\u003e\n\u003cp\u003eIt is unarguable that MDD qualifies as a clinical syndrome. DSM 5 outlines the core symptoms (sadness and loss of interest) and a range of associated depressive symptoms (5). These include changes in weight or appetite, changes in sleep pattern, psychomotor retardation or agitation, fatigue, worthlessness or guilt, impaired concentration or indecisiveness and suicidal thoughts or behaviors (6), which can broadly be classified into affective, somatic and cognitive domains (7,8).\u003c/p\u003e\n\u003cp\u003eWhile the DSM-5 relies on the nine criterion symptoms for MDD, common rating scales comprise multiple items which are not part of the DSM criteria (9). For instance, the Beck Depression Inventory (BDI)(10) includes irritability, pessimism, and feelings of being punished; the Hamilton Rating Scale for Depression (HRSD)\u0026nbsp;(11)\u0026nbsp;covers anxiety, sexual dysfunctions, hypochondriasis, and insights into the depressive illness; and the Center for Epidemiological Studies Depression Scale (CESD)(12) includes frequent crying, talking less, and perceiving others as unfriendly. This inconsistency implies a lack of consensus regarding the construct and measurement of depression\u0026nbsp;(9). Hence, worldwide use of DSM criteria to diagnose depression does not imply that diverse populations\u0026rsquo; clinical presentations are globally similar (13); and commonly used tools may not be fully representative of the diverse depressive symptomatology around the world.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlthough the core symptoms of depression, as outlined in the DSM, are widely recognized, MDD has inarguably heterogenous clinical presentation varying across individuals and settings\u0026nbsp;(14). Several studies have reported major differences in symptom clustering and severity among different populations (14,15). In a validation study of brief depression questionnaires conducted in Ethiopia that recruited 306 participants, 5.9 % were diagnosed with MDD using a culturally adopted version of Mini-International Neuropsychiatric Interview (MINI) (2). In this study, cases reported having irritability more commonly than the two core symptoms of DSM, suggesting the need to consider irritability as a core symptom of depression. In addition, somatic symptoms, which were given less emphasis on DSM, were the most commonly endorsed symptoms in this study (16).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis heterogeneity in clinical presentation may be influenced by various factors, including biological determinants such as genetic variations\u0026nbsp;(17,18), psychological and sociocultural differences such as varying attitudes, beliefs, and stigma. This influences how people experience, interpret, perceive, and seek medical help for depressive symptoms\u0026nbsp;(19,20) posing significant challenges in the recognition and detection of depression by health care providers.\u003c/p\u003e\n\u003cp\u003eAlarmingly low detection rates of depressive disorders by primary care providers have been reported from low-and-middle-income-countries (LMICs)\u0026nbsp;(21), including Ethiopia (22). A qualitative study conducted in rural Ethiopia that shed a light on the understandings of depression among community members and primary care attendees highlighted that cultural beliefs and explanatory models shape how symptoms are understood, reported and recognized by health care providers\u0026nbsp;(20). \u0026nbsp;In this study, non-DSM somatic and emotional symptoms of depression were commonly reported by patients and were identified as local idioms of distress\u0026nbsp;(20).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn Ethiopia, clinical practice and research on depression has heavily relied on the recognition of DSM symptoms such as sadness, anhedonia, and sleep disturbances. Although some studies (2,22) have identified somatic symptoms and irritability as common manifestations of depression, there remains a lack of evidence on the broader presentations outside of DSM that include locally relevant idioms of distress in Ethiopian clinical settings. Beyond the symptom count, little is understood about the syndromic presentation in clinical settings, and which domains, such as affective, somatic or cognitive, are predominantly perceived as most distressing by patients. Understanding these nuances aligns with recent efforts to improve the detection of depression in primary care by refining detection strategies and tailoring treatment approaches to be more contextually relevant (23). Building on such initiatives, our study aimed to identify the common and most distressing presentations and domains of depressive symptoms; and to explore the association between socio-demographic factors and the symptom domains among patients who are receiving outpatient care for depressive disorders in tertiary hospitals in Addis Ababa, Ethiopia.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy setting, design and study period:\u003c/strong\u003e We recruited study participants from outpatient departments of psychiatry at Tikur Anbessa Specialized Hospital (TASH), Zewditu Memorial Hospital (ZMH), and Yekatit -12 Hospital. The three hospitals are tertiary hospitals located in the capital city of Ethiopia. The hospitals run psychiatric outpatient services which are given in collaboration with the Department of Psychiatry, College of Health Sciences, Addis Ababa University. We used health facility based cross sectional study design and the data collection was conducted from June 2021 until September 2021.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample size and recruitment of study participants\u003c/strong\u003e: We estimated a sample size of 165 with the following assumptions: assumed depression prevalence of 11% based on a previous study (24), 5% margin of error, 95% confidence in the estimate, and 10% non-response rate. The source population was all patients who have been receiving psychiatric outpatient care at one of the three hospitals within the past two years from the time of data. \u0026nbsp;The inclusion criteria were \u0026ndash; being over 18 years of age, having received a diagnosis of Major depressive disorder or Persistent Depressive Disorder by a psychiatry resident or a psychiatrist. The diagnosis should have been newly made in the past one year, or if it was made over a year ago, the patient must not have been in remission during the study period. In addition, the participants must have been able to communicate in Amharic and be able to give informed consent.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePatients who had other comorbid mental health or medical conditions, had a diagnosis of depressive disorder that was made over one year ago and were in remission during the study period, those who had communication barriers, or were acutely disturbed or distressed during data collection were not eligible for the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection tools and data collection approaches:\u0026nbsp;\u003c/strong\u003eWe collected data through a questionnaire designed for extracting sociodemographic and clinical factors from clinical charts. This included age, sex, address, educational status, marital status, religion, occupation, economic status, chief complaint of the patient, duration of illness, initial diagnosis, most distressing symptoms, start of treatment and types of treatment they are involved in.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAdditionally, we conducted face-to-face interviews using the Amharic version of Patient Health Questionnaire (PHQ-9) and PHQ-15. The PHQ-9 is a widely used depression screening scale globally (25). It consists of 9 items that follow DSM 5 and it has been validated and extensively used locally (25). The PHQ-15 is a 15 items screening instrument that has been used as a tool in several local studies to screen for somatic symptoms and has demonstrated high reliability and validity among the Ethiopian population (26).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor the purpose of this study we added one item, \u0026ldquo;burning sensation in the head\u0026rdquo;, to the PHQ- 15, which is a local somatic idiom commonly identified in the Ethiopian settings (27,28). We omitted two items, namely, trouble sleeping and fatigue, from PHQ 15 as they are items included in the PHQ 9. Similarly, we supplemented the PHQ-9 with three items: irritability, noise intolerance and urge to shout/disappear/run which have been identified as common local idioms of distress (20,29).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe recruitment process involved selecting eligible participants consecutively, starting from the most recently recorded ones, until the planned sample size was attained. Data was collected at the three hospitals by psychiatry residents who were trained at the beginning of the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOperational definitions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the 26 items were categorized into four main symptom domains, \u0026ldquo;Affective symptoms\u0026rdquo;, \u0026ldquo;Somatic symptoms\u0026rdquo;, \u0026ldquo;Cognitive symptoms\u0026rdquo; and \u0026ldquo;Other symptoms\u0026rdquo;, based on evidence from literature (30, 31,\u0026nbsp;32, 33,34,20) including meta-analysis of factor- analytic studies (35)\u0026nbsp;and expert consensus.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026ldquo;Affective symptoms\u0026rdquo; \u0026ndash;\u0026nbsp;\u003c/strong\u003erefer to the changes in the patient\u0026rsquo;s emotional state. Items in this domain include - \u003cem\u003elittle interest or pleasure in doing things, feeling down, depressed or hopeless and irritability\u003c/em\u003e (32).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026ldquo;Somatic symptoms\u0026rdquo; \u0026ndash;\u0026nbsp;\u003c/strong\u003erefer to bodily experiences or physical complaints of patients. Items in this domain include - \u003cem\u003etired/ low energy, sleep problem, appetite problem, stomach pain, back pain, pain in your arms, legs, or joints (knees, hips, etc), headaches, burning sensation in the head, chest pain, dizziness, fainting spells, feeling your heart pound or race, shortness of breath, pain or problems during sexual intercourse, constipation, loose bowels, or diarrhea, nausea, gas, or indigestion, menstrual cramps or other problems with your periods\u003c/em\u003e [Women only] (33).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026ldquo;Cognitive symptoms\u0026rdquo; \u0026ndash;\u003c/strong\u003e refer to changes in mental processes and negative thoughts or beliefs. Items in this domain include - \u003cem\u003efeeling\u003c/em\u003e\u003cem\u003e\u0026nbsp;bad about self, suicidal thoughts\u0026nbsp;\u003c/em\u003e\u003cem\u003eand trouble concentrating\u003c/em\u003e (34).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026ldquo;Other symptoms\u0026rdquo; \u0026ndash;\u0026nbsp;\u003c/strong\u003erefer to behavioral, perceptual or culturally specific expressions of distress that do not fit well in the other domains. These include \u003cem\u003epsychomotor\u003c/em\u003e\u003cem\u003e\u0026nbsp;agitation/ retardation, noise intolerance and urge to disappear/ run/shout\u003c/em\u003e (20).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted data entry, cleaning and analysis using SPSS version 26. Descriptive summary was used to understand the data and cross tabulations with measures of associations were used to investigate association of depressive disorder symptoms with sociodemographic and clinical factors.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eBackground characteristics of the study participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSociodemographic characteristics\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 165 study participants were recruited from the study sites and all were successfully interviewed, making a response rate of 100%. The age ranged from 18 to 66, with the largest proportion, 48.5% (n=80), being in the age range of 20 to 40 years. The majority, 62.4% (n=103), were females, 42.4% (n=70) were single, 54.5% (n=90) were employed, 85.5% (n=141) were residents of Addis Ababa, and 90.9% (n=150) had some formal education. (see \u003cstrong\u003eTable -1)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Characteristics\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn 92.7% (n= 153) of the participants, the clinical diagnosis was MDD, of whom 2.6% (n=4) were specified to have anxious distress. Those with a diagnosis of PDD were 6.7% (n=11), while only one participant had a diagnosis of both PDD and MDD.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe mean duration of treatment was 3.6 years. Newly diagnosed study participants who had not yet started treatment were 13.3% (n=22) and these had the shortest duration of follow-up. From all the study participants, the longest duration of treatment was 18 years; 47.3% (n=78) reported receiving both psychotherapeutic and pharmacological care, while 43% (n=71) received pharmacotherapy only and 9.7% (n=16) received psychotherapy only.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFeeling down, depressed or hopeless\u003c/em\u003e was endorsed in 90.3% (n= 149), making it the most frequently endorsed symptom, while \u003cem\u003efainting spells\u003c/em\u003e was the least reported, 10.9% (n=18), symptom. \u0026nbsp;Eleven out of the total of 26 items were endorsed by most of the study participants, including the two items that were added as locally common idioms of distress- \u003cem\u003enoise intolerance\u003c/em\u003e 77% (n=127) and \u003cem\u003eirritability\u003c/em\u003e 72.7% (n=120). \u003cstrong\u003eFigure 1\u003c/strong\u003e presents the symptom profile of 165 study participants with depression. \u003cem\u003eSleep problems\u003c/em\u003e was the most commonly reported symptom as being the most distressing symptom followed by having a \u003cem\u003edepressed mood\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003eAlmost all, the study participants endorsed having experienced at least one symptom from the \u0026ldquo;Somatic\u0026rdquo;, \u0026ldquo;Affective\u0026rdquo; and \u0026ldquo;Other symptoms\u0026rdquo; domains, 98.8%, 96.4% and 93.3% respectively, while only 78% reported having cognitive difficulties \u003cstrong\u003e(Figure 2).\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA significant association was found between the educational level and religious status of study participants with the endorsement of symptoms from the \u0026ldquo;Other symptoms\u0026rdquo; domain. Most of those whose educational level was at elementary and higher level of education endorsed symptoms from the \u0026ldquo;Other symptoms\u0026rdquo; domain (P-value of 0.006) as shown in \u003cstrong\u003eTable 2\u003c/strong\u003e. Newly diagnosed patients were found to have significantly higher endorsement of cognitive symptoms than those who were on follow up (P-value of 0.049)/ See \u003cstrong\u003eTable 3\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eThere was no statistically significant association between clinical and sociodemographic characteristics and endorsing symptoms in the \u0026ldquo;Affective symptoms\u0026rdquo; and \u0026ldquo;Somatic symptoms\u0026rdquo; domains of depression.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmong participants who reported their \u003cem\u003emost distressing\u003c/em\u003e symptoms (n=138), symptoms in the \u0026ldquo;Affective symptoms\u0026rdquo; domain were the most frequently endorsed, reported by 58(42.03%) participants, while those in the \u0026ldquo;Other symptoms\u0026rdquo; domain were the least frequently endorsed, reported by just 1(0.73%) participant. See \u003cstrong\u003eFigure 3.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe conducted this study in tertiary hospitals in Addis Ababa with the aim of exploring the common symptom presentations of patients receiving outpatient care for depressive disorders. To the best of our knowledge, this is the first study that explored the common symptoms and syndromic profile of depressive disorders, beyond the commonly utilized diagnostic tools, in an urban clinical context of Ethiopia. Our study yielded the following key findings; first, the most commonly reported depressive symptoms were \u003cem\u003efeeling down, depressed, or hopeless\u003c/em\u003e, while \u003cem\u003efainting spells\u003c/em\u003e were the least common. Second, among symptom domains, somatic symptoms were the most commonly reported symptoms with 98.8% of all participants endorsing at least one somatic symptom, closely followed by affective and other symptoms, while cognitive symptoms were the least reported symptoms. Third, among individual symptoms, \u003cem\u003esleep problems\u003c/em\u003e were reported as the \u003cem\u003emost distressing\u003c/em\u003e, whereas the \u0026ldquo;Affective symptoms\u0026rdquo; domain was the most frequently reported \u003cem\u003emost distressing\u003c/em\u003e domain. Fourth, a significant association was found between the educational level of participants and endorsing symptoms in the \"Other symptoms\" domain, while clinical status (New vs Follow up patient) showed significant association with the endorsement of symptoms in the \u0026ldquo;Cognitive symptoms\u0026rdquo; domain.\u003c/p\u003e\u003cp\u003eThe DSM lists \u0026ldquo;persistently depressed mood\u0026rdquo; as one of the two required core symptoms for the clinical diagnosis of MDD (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Our findings of sadness and hopelessness as the most frequently reported symptoms also demonstrate that such emotional symptoms are cardinal features of depressive disorders. This is in line with previous cross-cultural studies(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) that show that \u0026ldquo;feeling sad, low or hopeless\u0026rdquo; are nearly universal symptoms of depression, including in LMICs like Ethiopia (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). However, our findings might be expected given that participants were recruited from a clinical setting where the DSM criteria is used for diagnoses. Although it is not one of the two core symptoms, our study found \u003cem\u003efatigue\u003c/em\u003e as the second most reported symptom (81.8%) of depression. This is in agreement with studies across various settings that have recognized fatigue as the most prevalent (up to 95%) and often underappreciated symptom of depression (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan additionalcitationids=\"CR40\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eExcept for the \u0026ldquo;Cognitive Symptoms\u0026rdquo; domain, which showed the lowest frequency, all domains generally had comparable frequency of reporting with \u0026ldquo;Somatic symptoms\u0026rdquo;, which had the highest frequency. This is in line with studies conducted in LMICs, including Ethiopia, that have consistently reported that somatic challenges were often expressed alongside emotional symptoms in depressive presentations (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). In this study, almost all of the participants reported experiencing somatic symptoms in combination with affective and other symptoms.\u003c/p\u003e\u003cp\u003eIn addition, our study found that sleep problems were the most frequently reported \u003cem\u003emost distressing\u003c/em\u003e symptoms. Our findings are in line with studies that have explained that sleep problems are not only common but also reflect a neurobiological disruption making them one of the core and pervasive symptoms of depression (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). They can be drivers of mood worsening and points of suffering with significant impact on quality of life(\u003cspan additionalcitationids=\"CR45\" citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e) and risk of suicide(\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). They are shown to frequently lead to active help-seeking demonstrating the degree of distress and burden associated with it.\u003c/p\u003e\u003cp\u003eSomatic symptoms have been widely recognized as one of the culture-specific expressions of distress that carry unique meaning but can be easily misinterpreted and misdiagnosed (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). As an example, this was demonstrated in a study which compared Chinese and Australian Caucasian patients, where the majority of Malaysian Chinese reported somatic symptoms, and only a small proportion of Australian Caucasians reported these symptoms (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).This shows that culture, illness perception, stigma and health- care seeking norms shape the expression and presentation of symptoms of depression (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). In addition, the high co-morbidity between physical illness and depression (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e), coupled with the tendency of patients with medical conditions to express psychological distress through physical symptoms (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), all reinforce the dominance of somatic symptoms. The co-morbid medical illnesses might necessitate diagnosis and treatment by their own right.\u003c/p\u003e\u003cp\u003eThe weight that culture bears on the experience and expression of distress in Ethiopia is also reflected in the proportion of patents who endorsed the locally identified idioms of distress, such as, irritability (72.7%) and noise intolerance (77%). Although irritability does not appear in standard diagnostic frameworks for adult depressive disorders, studies indicate that over 50% of adults with MDD report having it (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e). Studies across LMICs, including Ethiopia, confirm that locally salient symptoms, such as irritability, noise intolerance and somatic pain, frequently emerge in primary care settings but are rarely detected as they do not match diagnostic categories. In a study that aimed to improve detection of depression in PHC settings in rural Ethiopia, a four-item screening tool, that included irritability and noise intolerance, in addition to the core symptoms of depression, was pilot tested (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). This tool outperformed the two-item tool with core symptoms alone in detecting depression, highlighting the clinical relevance of the additional symptoms.\u003c/p\u003e\u003cp\u003eIn our study, although the \u0026ldquo;Cognitive Symptoms\u0026rdquo; domain showed the lowest frequency of reporting (78.2%) as a domain, comparison with previous studies warrants caution. Previous studies conducted in Ethiopia have reported lower prevalence rates, up to 54% (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e), similar to a recent systematic review and meta-analysis that found pooled prevalence of cognitive impartment in MDD to be 53% (95% CI: 41\u0026ndash;64%) (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e). Our finding of higher frequency of cognitive symptom reporting is likely due to the classification of symptoms such as \u003cem\u003efeeling bad about self\u003c/em\u003e and \u003cem\u003esuicidal thoughts\u003c/em\u003e in this domain, and our reliance on self- report of the symptoms as opposed to using standard tools to measure cognitive deficits. Comparison with previous findings was difficult due to the lack of PhQ-9 item level data among patients with depressive disorders from similar settings.\u003c/p\u003e\u003cp\u003eOur analyses also demonstrated that the endorsement of cognitive symptoms was significantly associated with having a newly diagnosed and untreated depressive disorder. This also needs similar caution in interpretation as above. However, this finding corroborates previous studies that have established that cognitive impairments and suicidal thoughts - in the same category in our study- are associated with acute and untreated phases of depression in addition to illness severity (\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan additionalcitationids=\"CR58\" citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn Summary, we found that the core symptoms of depression were among the most frequently endorsed individual symptoms, while somatic symptoms had the highest frequency of reporting as a domain, closely followed by the other two symptom domains. This was coupled with findings of a somatic symptom, sleep problem, as the most frequently reported \u003cem\u003emost distressing\u003c/em\u003e individual symptom, while affective symptoms were the most reported \u003cem\u003emost distressing\u003c/em\u003e symptoms as a domain. This shows that diagnosis will remain inaccurate without proper enquiry of both affective and somatic symptoms highlighting the need to incorporate the commonly endorsed somatic symptoms in diagnostic tools, while paying attention to locally recognized expressions of distress (\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e). However, further studies are needed to determine the specific symptoms and weight that they should carry in the diagnosis of depressive disorders in settings like ours.\u003c/p\u003e\u003cp\u003eOur study has a few limitations that require consideration. First, due to its cross-sectional nature, causal inferences can be limited. Second, reports of the most distressing symptoms may have been subject to bias by respondents\u0026rsquo; current clinical presentation, as some had been in care for up to two years and may have been responding to treatment. Third, cognitive and physical symptoms were assessed using self-report and medical records alone, without objective measures. Cognitive symptoms were captured with only two PHQ-9 items, which may underestimate their prevalence, indicating the need for more comprehensive assessment tools in future research.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study demonstrated that patients seeking care for depressive disorders in the urban context of Ethiopia had symptom presentations that were dispersed across domains, including culturally prevalent expressions of distress merging as prominent. This reveals that peculiarities in social, cultural and religious contexts have impacts on emotional expression; and depressive symptoms may manifest in ways that diverge from conventional diagnostic tools.\u003c/p\u003e\u003cp\u003eOur findings highlight the need for clinicians to look beyond core affective symptoms and attend to all domains of distress, avoiding narrow diagnostic checklist. Treatment approaches that address the full spectrum of symptomatology, including the local idioms of distress, should be adapted. In addition, individualized approaches should be tailored to focus on symptoms that cause significant suffering.\u003c/p\u003e\u003cp\u003eThis calls for the development and validation of brief, culturally informed screening instruments that integrate both commonly endorsed and severely distressing symptoms, as well as prospective studies that capture evolving symptom profiles over time. Fundamentally, progress towards a more holistic and context-sensitive clinical and research approaches could narrow the gap between global diagnostic frameworks and the lived experiences of patients in settings like ours.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAA- Addis Ababa\u003c/p\u003e\n\u003cp\u003eBDI-Beck depression inventory\u003c/p\u003e\n\u003cp\u003eCDC- Centers for disease control\u003c/p\u003e\n\u003cp\u003eCESD- Center for epidemiological study of depression scale\u003c/p\u003e\n\u003cp\u003eDSM- Diagnostic statistical manual\u003c/p\u003e\n\u003cp\u003eHAMD-Hamilton depression rating scale\u003c/p\u003e\n\u003cp\u003eLAMIC- Low- and middle-income countries\u003c/p\u003e\n\u003cp\u003ePDD- Persistent depressive disorder\u003c/p\u003e\n\u003cp\u003ePHQ- Patient health questionnaire\u003c/p\u003e\n\u003cp\u003eSRQ- Self reporting questionnaire\u003c/p\u003e\n\u003cp\u003eSSI- Somatic symptoms inventory\u003c/p\u003e\n\u003cp\u003eTASH- Tikur Anbessa specialized hospital\u003c/p\u003e\n\u003cp\u003eUSA- United States of America\u003c/p\u003e\n\u003cp\u003eZMH- Zewditu Memorial Hospital\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical permission was sought from the Research Ethics Committee of Department of Psychiatry, College of Health Sciences, and Addis Ababa University (Ethical Clearance Ref. No: MF/PSY/167/13 and MF/PSY/168/13). Approval was also sought from each of the hospitals where the data was collected. The study was conducted in accordance with the Declaration of Helsinki. When patients that required intervention (e.g. mismanagement, risks of self-harm, non-adherence) were identified, they were linked with treating psychiatrists working at the specific hospitals.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBefore enrollment into the study, the purpose of the study was briefly explained to all participants and informed consent was sought. The filled questionnaires were kept anonymous and confidential.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was funded by Addis Ababa University as part of a research study conducted to fulfill requirements for a Certificate in Psychiatry for ES.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eES and BM conceived and designed the study. ES and BM reviewed the literature; ES, BM and GM wrote the original draft. ES conducted the statistical analysis; ES, NS, GM and BM were involved in data interpretation, manuscript reviewing and editing. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to acknowledge the contribution of clinicians and coordinators working at each study unit, who facilitated the data collection process.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organisation. Depression and other common mental disorders: global health estimates. World Health Organization. 2017; \u003c/li\u003e\n\u003cli\u003eGoodmann DR, Daouk S, Sullivan M, Cabrera J, Liu NH, Barakat S, et al. Factor analysis of depression symptoms across five broad cultural groups. 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Vol. 24, Ethiopian journal of health sciences. 2014. \u003c/li\u003e\n\u003cli\u003eGelaye B, Williams MA, Lemma S, Deyessa N, Bahretibeb Y, Shibre T, et al. Validity of the patient health questionnaire-9 for depression screening and diagnosis in East Africa. Psychiatry Res. 2013;210(2). \u003c/li\u003e\n\u003cli\u003eZeleke W, Minaye A. Mental Health and Somatic Distress among Ethiopian Migrant Returnees from the Middle East. Int J Ment Health Psychiatry. 2015;01(02). \u003c/li\u003e\n\u003cli\u003eYoungmann R, Minuchin-Itzigsohn S, Barasch M. Manifestations of Emotional Distress among Ethiopian Immigrants in Israel: PatienT and Clinician Perspectives. Transcult Psychiatry. 1999;36(1). \u003c/li\u003e\n\u003cli\u003eSenturk V, Hanlon C, Medhin G, Dewey M, Araya M, Alem A, et al. Impact of perinatal somatic and common mental disorder symptoms on functioning in Ethiopian women: The P-MaMiE population-based cohort study. J Affect Disord. 2012;136(3). \u003c/li\u003e\n\u003cli\u003eDemissie M, Birhane R, Hanlon C, Eshetu T, Medhin G, Minaye A, et al. Developing interventions to improve detection of depression in primary healthcare settings in rural Ethiopia. BJPsych Open. 2024;10(2). \u003c/li\u003e\n\u003cli\u003eDe Miranda Azevedo R, Roest AM, Hoen PW, De Jonge P. Cognitive/affective and somatic/affective symptoms of depression in patients with heart disease and their association with cardiovascular prognosis: A meta-analysis. Vol. 44, Psychological Medicine. 2014. \u003c/li\u003e\n\u003cli\u003eSchrijvers D, Hulstijn W, Sabbe BGC. Psychomotor symptoms in depression: A diagnostic, pathophysiological and therapeutic tool. Vol. 109, Journal of Affective Disorders. 2008. \u003c/li\u003e\n\u003cli\u003eKennedy SH. Core symptoms of major depressive disorder: Relevance to diagnosis and treatment. Dialogues Clin Neurosci. 2008;10(3). \u003c/li\u003e\n\u003cli\u003eVaccarino AL, Sills TL, Evans KR, Kalali AH. Prevalence and association of somatic symptoms in patients with Major Depressive Disorder. J Affect Disord. 2008;110(3). \u003c/li\u003e\n\u003cli\u003eRoca M, Vives M, L\u0026oacute;pez-Navarro E, Garc\u0026iacute;a-Campayo J, Gili M. Cognitive impairments and depression: A critical review. Actas Esp Psiquiatr. 2015;43(5). \u003c/li\u003e\n\u003cli\u003eHuang C, Chen JH. Meta-Analysis of the Factor Structures of the Beck Depression Inventory\u0026ndash;II. Assessment. 2015;22(4). \u003c/li\u003e\n\u003cli\u003ePatel V, Kleinman A. Poverty and common mental disorders in developing countries. Vol. 81, Bulletin of the World Health Organization. 2003. \u003c/li\u003e\n\u003cli\u003eSweetland AC, Belkin GS, Verdeli H. Measuring depression and anxiety in sub-saharan africa. Depress Anxiety. 2014;31(3). \u003c/li\u003e\n\u003cli\u003eFekadu A, Hanlon C, Medhin G, Alem A, Selamu M, Giorgis TW, et al. Development of a scalable mental healthcare plan for a rural district in Ethiopia. British Journal of Psychiatry. 2016;208. \u003c/li\u003e\n\u003cli\u003ePatel V, Abas M, Broadhead J, Todd C, Reeler A. Depression in developing countries: Lessons from Zimbabwe. Vol. 322, British Medical Journal. 2001. \u003c/li\u003e\n\u003cli\u003eGhanean H, Ceniti AK, Kennedy SH. Fatigue in Patients with Major Depressive Disorder: Prevalence, Burden and Pharmacological Approaches to Management. Vol. 32, CNS Drugs. 2018. \u003c/li\u003e\n\u003cli\u003ePae CU, Lim HK, Han C, Patkar AA, Steffens DC, Masand PS, et al. Fatigue as a core symptom in major depressive disorder: Overview and the role of bupropion. Vol. 7, Expert Review of Neurotherapeutics. 2007. \u003c/li\u003e\n\u003cli\u003eRiemann D, Berger M, Voderholzer U. Sleep and depression - Results from psychobiological studies: An overview. Biol Psychol. 2001;57(1\u0026ndash;3). \u003c/li\u003e\n\u003cli\u003ePandi-Perumal SR, Monti JM, Burman D, Karthikeyan R, BaHammam AS, Spence DW, et al. Clarifying the role of sleep in depression: A narrative review. Vol. 291, Psychiatry Research. 2020. \u003c/li\u003e\n\u003cli\u003eLovato N, Gradisar M. A meta-analysis and model of the relationship between sleep and depression in adolescents: Recommendations for future research and clinical practice. Vol. 18, Sleep Medicine Reviews. 2014. \u003c/li\u003e\n\u003cli\u003eNutt DJ, Wilson S, Paterson L. Sleep disorders as core symptoms of depression. Dialogues Clin Neurosci. 2008;10(3). \u003c/li\u003e\n\u003cli\u003eGoodman ML, Lee M, Springer A, Schick V, Vaughan E, Markham C, et al. Sleep disturbance as a precursor to anxiety, depression, and PTSD among rural Kenyans: A cross-lagged panel analysis from a rural Kenyan interventional cohort. J Sleep Res. 2024;33(4). \u003c/li\u003e\n\u003cli\u003eGelaye B, Okeiga J, Ayantoye I, Berhane HY, Berhane Y, Williams MA. Association of suicidal ideation with poor sleep quality among Ethiopian adults. Sleep Breath. 2016 Dec;20(4):1319\u0026ndash;26. \u003c/li\u003e\n\u003cli\u003eKirmayer LJ, Nutt, Lecrubier, Lepine, Davidson. Cultural variations in the clinical presentation of depression and anxiety: Implications for diagnosis and treatment. Vol. 62, Journal of Clinical Psychiatry. 2001. \u003c/li\u003e\n\u003cli\u003eAl Busaidi ZQ. The concept of somatisation: A cross-cultural perspective. Vol. 10, Sultan Qaboos University Medical Journal. 2010. \u003c/li\u003e\n\u003cli\u003eSimon GE, VonKorff M, Piccinelli M, Fullerton C, Ormel J. An International Study of the Relation between Somatic Symptoms and Depression. New England Journal of Medicine. 1999;341(18). \u003c/li\u003e\n\u003cli\u003eDar\u0026eacute; LO, Bruand PE, G\u0026eacute;rard D, Marin B, Lameyre V, Boum\u0026eacute;di\u0026egrave;ne F, et al. Co-morbidities of mental disorders and chronic physical diseases in developing and emerging countries: A meta-analysis. BMC Public Health. 2019;19(1). \u003c/li\u003e\n\u003cli\u003eBorie YA, Tamiso A, Gutema K, Jisso M, Deribe B, Fikre R, et al. Psychological distress and its associated factors among people with specific chronic conditions (diabetes and/or hypertension) in the Sidama region of southern Ethiopia: A cross-sectional study. PLoS One. 2024;19(7):e0303196. \u003c/li\u003e\n\u003cli\u003eFava M, Hwang I, Rush AJ, Sampson N, Walters EE, Kessler RC. The importance of irritability as a symptom of major depressive disorder: results from the National Comorbidity Survey Replication. Mol Psychiatry. 2010 Aug;15(8):856\u0026ndash;67. \u003c/li\u003e\n\u003cli\u003eAmbaw A, Desalegn GT. Magnitude and correlates of cognitive impairment among major depressive disorder patients in Addis Ababa: Institution based cross-sectional study. BMC Res Notes. 2019;12(1). \u003c/li\u003e\n\u003cli\u003eMekuriaw BY, Wondmu H, Asfaw M, Kassaw C, Molla A. Cognitive impairment and associated factors among patients with mood disorders receiving care at public hospitals in Gedeo zone, Southern Ethiopia. Soc Psychiatry Psychiatr Epidemiol. 2025 May 29; \u003c/li\u003e\n\u003cli\u003eMoges AM. Prevalence of Cognitive Impairment among major depressive disorder patients: A systematic review and meta-analysis. 2025. \u003c/li\u003e\n\u003cli\u003eGalimberti C, Bosi MF, Volont\u0026egrave; M, Giordano F, Dell\u0026rsquo;Osso B, Vigan\u0026ograve; CA. Duration of untreated illness and depression severity are associated with cognitive impairment in mood disorders. Int J Psychiatry Clin Pract. 2020;24(3). \u003c/li\u003e\n\u003cli\u003eKalin NH. Insights into suicide and depression. Vol. 177, American Journal of Psychiatry. 2020. \u003c/li\u003e\n\u003cli\u003eLi M, Zhong N, Lu S, Wang G, Feng L, Hu B. Cognitive behavioral performance of untreated depressed patients with mild depressive symptoms. PLoS One. 2016;11(1). \u003c/li\u003e\n\u003cli\u003eKirmayer LJ, Robbins JM, Dworkind M, Yaffe MJ. Somatization and the recognition of depression and anxiety in primary care. American Journal of Psychiatry. 1993;150(5). \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1: Background characteristics of study participants\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"485\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.866%;\"\u003e\n \u003cp\u003eParticipant Characteristics\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.1753%;\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003cp\u003eN=165\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.9588%;\"\u003e\n \u003cp\u003ePercent (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge in years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.866%;\"\u003e\n \u003cp\u003eBelow 20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.1753%;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.9588%;\"\u003e\n \u003cp\u003e4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.866%;\"\u003e\n \u003cp\u003e20 to 40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.1753%;\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.9588%;\"\u003e\n \u003cp\u003e48.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.866%;\"\u003e\n \u003cp\u003e40 to 60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.1753%;\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.9588%;\"\u003e\n \u003cp\u003e42.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.866%;\"\u003e\n \u003cp\u003eAbove 60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.1753%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.9588%;\"\u003e\n \u003cp\u003e4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.866%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.1753%;\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.9588%;\"\u003e\n \u003cp\u003e37.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.866%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.1753%;\"\u003e\n \u003cp\u003e103\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.9588%;\"\u003e\n \u003cp\u003e62.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlace of residence\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.866%;\"\u003e\n \u003cp\u003eAddis Ababa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.1753%;\"\u003e\n \u003cp\u003e141\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.9588%;\"\u003e\n \u003cp\u003e85.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.866%;\"\u003e\n \u003cp\u003eOut of Addis Ababa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.1753%;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.9588%;\"\u003e\n \u003cp\u003e14.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.866%;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.1753%;\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.9588%;\"\u003e\n \u003cp\u003e42.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.866%;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.1753%;\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.9588%;\"\u003e\n \u003cp\u003e38.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.866%;\"\u003e\n \u003cp\u003eDivorced/Separated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.1753%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.9588%;\"\u003e\n \u003cp\u003e3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.866%;\"\u003e\n \u003cp\u003eWidowed/Widower\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.1753%;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.9588%;\"\u003e\n \u003cp\u003e15.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOccupation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.866%;\"\u003e\n \u003cp\u003eEmployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.1753%;\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.9588%;\"\u003e\n \u003cp\u003e54.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.866%;\"\u003e\n \u003cp\u003eUnemployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.1753%;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.9588%;\"\u003e\n \u003cp\u003e15.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.866%;\"\u003e\n \u003cp\u003eHousewife\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.1753%;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.9588%;\"\u003e\n \u003cp\u003e14.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.866%;\"\u003e\n \u003cp\u003eStudent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.1753%;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.9588%;\"\u003e\n \u003cp\u003e9.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.866%;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.1753%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.9588%;\"\u003e\n \u003cp\u003e6.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReligion\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.866%;\"\u003e\n \u003cp\u003eMuslim\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.1753%;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.9588%;\"\u003e\n \u003cp\u003e14.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.866%;\"\u003e\n \u003cp\u003eOrthodox Christian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.1753%;\"\u003e\n \u003cp\u003e116\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.9588%;\"\u003e\n \u003cp\u003e70.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.866%;\"\u003e\n \u003cp\u003eProtestant Christian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.1753%;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.9588%;\"\u003e\n \u003cp\u003e13.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.866%;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.1753%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.9588%;\"\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevel of formal education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.866%;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.1753%;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.9588%;\"\u003e\n \u003cp\u003e9.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.866%;\"\u003e\n \u003cp\u003eElementary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.1753%;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.9588%;\"\u003e\n \u003cp\u003e18.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.866%;\"\u003e\n \u003cp\u003eHigh school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.1753%;\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.9588%;\"\u003e\n \u003cp\u003e32.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48.866%;\"\u003e\n \u003cp\u003eHigher level Education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.1753%;\"\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.9588%;\"\u003e\n \u003cp\u003e40.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Association of the \u0026ldquo;Other symptoms\u0026rdquo; domain of depression with sociodemographic characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"623\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 348px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026ldquo;Other symptoms\u0026rdquo; domain\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN=165\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;0.543\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eBelow 20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e7 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e20-40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e76(95.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e4(5.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e40-60\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e64(91.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e6(8.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eAbove 60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e7(87.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e1(12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0.334\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e56(90.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e6(9.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eFemale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e103\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e98(95.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e5(4.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eResidence\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0.202\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eAddis Ababa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e141\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e133(94.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e8(5.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eOut of Addis Ababa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e21(87.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e3(12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevel of Education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e13(86.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e2(13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eElementary\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e30(100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eHigh school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e46(85.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e8(14.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eHigher level education\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e65(98.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e1(1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOccupation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0.392\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eEmployed\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e89(95.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e4(4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eUnemployed\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e26(92.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e2(7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eHousewife\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e22(91.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e2(8.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eStudents\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e14(87.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e2(12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital Status\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0.170\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eSingle\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e65(92.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e1(7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eMarried\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e62(96.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e2(3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eWidowed\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e21(84.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e4(16.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eDivorced / separated\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e6(100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReligion\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0.027\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eMuslim\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e19(79.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e5(20.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eOrthodox Christian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e116\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e110(94.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e6(5.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eProtestant\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e23(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eOther\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e2(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinical status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eNew\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e21(95.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e1(4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eFollow up\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e143\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e133(93.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e10(7.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Association of \u0026quot;Cognitive symptoms\u0026rdquo; domain of depression with sociodemographic characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"664\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 348px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCognitive symptoms domain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN=165\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e0.370\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eBelow 20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e7(100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e20-40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e64(80.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e16(20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e40-60\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e51(72.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e19(27.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eAbove 60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e7(87.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1(12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e0.339\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e46(74.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e16(25.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eFemale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e103\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e83(80.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e20(19.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eResidence\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e0.430\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eAddis Ababa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e141\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e111(78.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e30(21.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eOut of Addis Ababa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e18(75.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e6(25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevel of Education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e0.061\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eNo formal education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e11(73.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e4(26.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eElementary\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e26(86.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e4(13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eHigh school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e36(66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e18(33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eHigher level education\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e56(84.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e10(15.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOccupation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e0.391\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eEmployed\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e72(77.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e21(22.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eUnemployed\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e20(71.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e8(28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eHouse wife\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e19(79.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e5(20.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eStudents\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e15(93.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1(6.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital Status\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e0.525\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eSingle\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e58(82.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e12(17.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eMarried\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e48(75.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e16(25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eWidowed\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e19(76.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e6(24.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eDivorced / separated\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e4(66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e2(33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReligion\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e0.123\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eMuslim\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e15(62.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e9(37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eOrthodox Christian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e116\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e91(78.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e25(21.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eProtestant\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e21(91.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e2(8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eOther\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e2(100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinical status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e0.049\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eNew\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e21(95.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1(4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eFollow up\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e143\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e108(75.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e35(24.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003e\u003c/strong\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Depression, Detection, Domains of depression, Symptoms of depression, Ethiopia","lastPublishedDoi":"10.21203/rs.3.rs-7495304/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7495304/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground-\u003c/strong\u003e While DSM-5 criteria for Depressive Disorders focuses on affective and cognitive symptoms, research in Ethiopia indicates that distress is commonly expressed through physical and culturally specific symptoms, reflecting differences in symptom expression across settings. In practice, screening tools and clinical interviews incorporate symptoms not included in DSM-5. We aimed to identify the common presentations and symptom domains of depressive disorders (somatic, cognitive, affective, and other) and examine their association with socio-demographic factors among outpatients in Ethiopia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods-\u003c/strong\u003e We conducted a facility-based cross-sectional study at three tertiary hospitals in Addis Ababa, Ethiopia. \u0026nbsp;Consecutive sampling was employed to include 165 adult patients who received outpatient care for depressive disorders at one of the three hospitals within the last two years. We collected data through a questionnaire designed for extracting sociodemographic and clinical factors from clinical records and face-to-face interviews. \u0026nbsp;We used the validated Amharic versions of PHQ-9 and PHQ-15 with additional symptoms identified as locally relevant idioms of distress to identify depressive symptoms. We analyzed the data using SPSS version 26 and employed descriptive statistical methods to summarize the data. Cross-tabulation was done to examine associations between sociodemographic and clinical characteristics and symptom domains.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults-\u003c/strong\u003e \u003cem\u003eFeeling down, depressed or hopeless\u003c/em\u003e was the most frequently endorsed symptom (90.3%) of depression. Nearly all participants endorsed the “Somatic symptoms” domain (98.8%), followed by “Affective symptoms” (96.4%), and “Other symptoms” (93.3%) domains — which include local idioms of distress — while only 78.2% endorsed symptoms in the “Cognitive symptoms” domain. Among participants who responded to the \u003cem\u003emost distressing symptom\u003c/em\u003e question, \u003cem\u003esleep problems\u003c/em\u003e were reported as the most distressing symptoms, while most of the reported symptoms, 58(35.2%), belonged to the “Affective symptoms” domain.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions-\u003c/strong\u003e Our study highlighted that patients seeking care for depressive disorders experience distress in ways that are not fully captured by routinely used diagnostic criteria such as the DSM-5. This calls for further research to understand broader clinical presentation of depressive disorders in Ethiopia, that would inform contextually sensitive and patient- centered approaches to diagnosis and treatment. This would ensure that even less commonly reported but highly distressing symptoms receive adequate attention in clinical care.\u003c/p\u003e","manuscriptTitle":"Common symptoms of depression among patients with depressive disorders receiving outpatient care in tertiary hospitals in Addis Ababa, Ethiopia: A cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-15 16:17:29","doi":"10.21203/rs.3.rs-7495304/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"31548c59-2740-47c7-baf4-e4045a934367","owner":[],"postedDate":"October 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-15T16:17:30+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-15 16:17:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7495304","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7495304","identity":"rs-7495304","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}