Gender Differences in Depression Levels at Refugee Camps in Duhok City, Kurdistan Region of Iraq

The difficult conditions and threats that refugees face are making a great possibility for destroying their health physically and mentally. Refugees are at risk for psychiatric morbidity, yet little is known about their serious mental health disorders such as depression. National and international studies about Iraqi refugees still not enough to understand their serious problems in everyday life in the refugee camps and the future consequences of their physical and psychological conditions. Studying the depression levels among refugees of ISIS war and comparing the severity of depression between adult males and females was to be the aim of the study. Method: A comparative study design, with a purposive sampling of total (68) adult participants, (31 males and 37 females) in the refugee camps in Duhok city, Kurdistan Region of Iraq from September, 2016 to October, 2017 and a depression questionnaire for data collection process have been used. Results: little differences between males and females levels and the severity of depression were revealed. The mild level was higher in females (57.14) percent compared with males (42.85) percent, but males have reported higher results in moderate level (53.57) percent compared to females (46.42) percent. The big difference in the sever level of depression was (80.0) percent for females compared with only (20.0) percent for males. Recommendations: psychological first aid and interventions are required for the refugees especially for the members whom lost family member(s), property, job and body parts during the war.


Introduction
Depressive disorder is one of the most common mental health problems that contribute significantly to the global disease burden (Varcarolis, 2006). According to the Centers for Disease Control and Prevention (CDC), 7.6 percent of people over the age of 12 have depression in any 2-week period. This is substantial and shows the scale of the issue.
According to the World Health Organization (WHO), depression is the most common illness worldwide and the leading cause of disability. They estimate that 350 million people are affected by depression, globally. Depression is likely to be due to a complex combination of factors that include: genetics, biological -changes in neurotransmitter levels, environmental, psychological and social (psychosocial) factors. Some people are at higher risk of depression than others; risk factors include: Life events -including bereavement, divorce, work issues, relationships with friends and family, financial problems, medical concerns, or acute stress like wars, accidents, and terror and childhood trauma. (MacGill, 2017). Depression symptoms can vary from mild to severe and can include: depressed mood, anhedonia, and altered cognitive function, feeling sad or having a depressed mood, Loss of interest or pleasure in activities once enjoyed, changes in appetiteweight loss or gain unrelated to dieting, trouble sleeping or sleeping too much, Loss of energy or increased fatigue, increase in purposeless physical activity (e.g., hand-wringing or pacing) or slowed movements and speech (actions observable by others), Feeling worthless or guilty, Difficulty thinking, concentrating or making decisions, and thoughts of death or suicide. For diagnosing depression symptoms need to last two weeks or more. Depression compared to other psychiatric disorders is among the most treatable of mental disorders (Schmidt, Shelton and Duman, 2011). The lifetime prevalence of MDD is approximately 17% of the population; about (80-90%) of people with depression have a good response to treatment . Almost every patient could have some relief from the symptoms, treatment includes: 1-Medication: antidepressant medications have no stimulating effect on people not experiencing depression, 2-Psychotherapy: Psychotherapy is sometimes used alone for treatment of mild depression; for moderate to severe depression, psychotherapy is often used in along with antidepressant medications. Cognitive behavioral therapy (CBT) has been found to be effective in treating depression, 3-Electroconvulsive Therapy (ECT) is a medical treatment most commonly used for patients with severe major depression or bipolar disorder who have not responded to other treatments. (APA, 2013), (NIMH, 2013), & .
A group of studies have been applied worldwide about depression among refugees and other similar subjects. A greater number of migrants' related stressors (MRS) were related to a higher severity level of depression in general (Wolf et al, 2017). A long asylum procedure was found to have a higher risk for common psychiatric disorders than adverse life events in Iraq (Laban et al, 2005).
A study about "Mental health symptoms in Iraqi refugees: posttraumatic stress disorder, anxiety, and depression" clarified that refugees suffer from high rates of mental illness symptoms than the general population since they have experienced extreme suffering and the accumulated effects of trauma, because of the diversity of regions from which the refugees originate (Jamil et al, 2007). In a study about "Depression among Vietnamese refugees in a primary care clinic" that refugees are at high risk for serious mental disorders and manifest cultural influences in their health behavior. Being a refugee is generally thought to be at increased risk for depression and other psychological problems (Lin, Ihle, and Tazuma,, 1985). Gorst-Unsworth and Goldenberg, 1998 have proved the importance in determining the severity of both Post Traumatic stress disorder and depressive reactions of the Iraqi refugees in their study about "Psychological Sequelae of torture and organized violence suffered by refugees from Iraq, trauma-related factors compared with social factors". Laban et al, 2004 conducted a study about Iraqi asylum seekers entitled "Impact of a long asylum procedure on the prevalence of psychiatric disorders in Iraqi asylum seekers in the Netherlands", they discovered that the prolonged duration of the asylum procedure is a serious risk factor for more serious psychiatric problems. Gerritsenet et al, 2006 in their study about "Physical and mental health of Afghan, Iranian and Somali asylum seekers and refugees living in the Netherlands" they investigated the physical and mental problems among refugees; they found that both physical and mental health problems like PTSD and depression have highly prevalence among refugees and asylum seekers. Taylor et al, 2014 conducted a survey among Iraqi refugees resettled in the United States to assess their physical and mental health status and the prevalence of emotional distress, anxiety, and depression was approximately 50%of participants. Another study has been applied by Slewa-Younan et al, 2015 they made a systematic review of literature reporting prevalence rates of posttraumatic stress disorder (PTSD) and depression amongst community samples of resettled Iraqi refugees. A study about "Prevalence and Predictors of Posttraumatic Stress and Depression Symptoms among Syrian Refugee Camp" was applied by Acarturk et al, 2017 and they studied the gender differences in depression levels.
Since ISIS attack lots of Iraqi people are migrated from their places, especially from the north of Iraq and they are spending their life in camps in other safe cities in the north. Living in camps is not easy, especially for a very long time (i.e.: more than three years), the refugees have lost their houses, jobs, studying, and some of them have lost family members, such difficulties and other daily problems in camps are risk factors for developing serious mental and psychological disorders such as depression. Carrying out such study was a necessity for understanding the suffering of young adults and to know more about their suffering and problems as a psychiatric and mental health nurse. Based on the previous studies that been applied to study the impact of migration on human psychology and the importance of this subject to be studied, the study aims to assess the levels of depression among young adults of both males and females in refugee camps and to detect the gender, age, and marital state differences in depression levels between males and females.

Methodology
A comparative study design, with a purposive sampling for the process of data collection has been used. The study was applied for male and female adults, randomly applied and every adult who agreed to participate, the sample composed of Kurds and Arabs also diverse religions (Muslim, Christian and Yazidi) at the refugee camps in Duhok city, Kurdistan Region of Iraq from September, 2016 to October, 2017. A depression questionnaire (Hamilton Depression Tool, Arabic version) with five different levels of depression (0-7) no depression, (8-13) mild, (14-18) moderate, (19-22) sever, and (23more) very sever (Fatim, 2016), was used which is composed of 17 items for assessing the severity of depression among the study sample, about (150) copies of the questionnaire were given to the samples but only (68) copies (31 males and 37 females) had been answered correctly and they were useful for the study. The data collection process started by taking an informed consent from University of Garmian in to the Camps Director in Duhok City, after visiting the camps and meeting the study population, the purpose of the study was explained for the study samples and after taking a verbal consent from each sample the questionnaire was given to them and was clarified to them carefully by the researcher with the aid of the local organizations' members in the area , the data collection process started at the end of September 2016 to the end of November 2016. A descriptive analysis has been used for comparing the results of depression levels between male and female participants. Results  According to the present table, there are simple differences between males and females regarding the levels and the severity of depression. The mild level was higher in females (57.14) percent compared with males (42.85) percent, but males have reported higher results in moderate level (53.57) percent compared to females (46.42) percent. The big difference in the sever level of depression was (80.0) percent for females compared with only (20.0) percent for males.   The table shows that the age group (18->29) years have higher frequency in both mild and moderate levels for both males and females, males (40.0) percent, females (50.0) for mild level, and males (33.3) percent, females (61.53) for the moderate level, with highest frequency for sever level in females . The age group (29->39) years have higher frequencies in females for mild level and higher frequencies in males for moderate level.  The table shows that married males reported higher frequencies than married females for both mild and moderate levels (86.6) percent and (73.3) percent respectively. Single females reported higher frequencies than single males in all mild, moderate, and sever levels (35.0) percent, (38.46) percent, and (75.0) percent respectively.

Discussion:
The higher levels of depression in females for both mild and sever levels compared to higher moderate level in males goes with Vonnahme et al, 2015 they found in their study that more women than men suffered from major depression, more women (26 %) than men (16 %) reported depression symptoms, also Angst et al, 2002, Murthy & Lakshminarayana 2006, and Tekin et al, 2016 clarified that men have reported fewer symptoms than women; as a consequence, men reached the diagnostic threshold less often and that women are more affected than men. This result disagrees with Nolen-Hoeksema 2001 andAngold et al 2002, whom showed that women are twice as likely as men to experience depression.
The age group (18->29) years are the most affected age group with depression in all mild, moderate and sever levels. This result disagrees with Mirowsky & Ross 1992, whom they found that depression reaches its highest levels at age of (80) years and older, while it appears to peak at ages of (35-45) years old (Beach, Sandeen & O'Leary, 1990). Hankin et al, 1998 showed that ages (15-18) years are at a critical time to depression because they reported the higher depression rates and the greater risk for depression and Jorm, 2000 who found no consistent pattern across studies for age differences in the occurrence of anxiety, depression or distress. The age group (18->29) years old have higher depression because it is a beginning of adulthood period, a new refreshing and happy life, studying or getting a job, and mostly getting married and building a new life. Spending months and years in camps and losing the future plans and hobbies in this age is considered to be more stressed than other periods of life.
The high levels of Depression in unmarried females go with Beach, Sandeen, & O'Leary, 1990. The high depression levels in married males disagrees with Beach, Sandeen, & O'Leary, 1990, they found that married men have lower rates of depression compared with unmarried men and Kessler & Essex 1982 in which they said that married people have comparatively low depression.
The unmarried females in the present study are having higher depression levels because they have difficult life situations in the camps and beside the stressful events that they are struggling with every day they are missing love and emotional support from a husband. Being married decreases the feelings of loneliness and can lower life stresses by sharing the responsibilities with a husband especially in Middle East women, because they have been raised so dependent on men.
The higher levels in married males is due to the stressful events that have suffered with war, poor economic conditions in the camps, they have lost jobs, houses, cars, and other necessary properties because of war and migration and also having no idea about the future and the months\ years that will be spent in camps.

Conclusions
The study came out with these conclusions: there are simple differences between males and females regarding the levels and the severity of depression. The mild and the sever levels were higher in females compared to males, but males have reported slightly higher results in moderate level compared to females. The age group (18->29) years have higher frequencies in both mild and moderate levels for both males and females, with highest frequency for sever level in females, which means that they are the most affected age group. The age group (29->39) years have higher frequencies in females for mild level and higher frequencies in males for moderate level. Married males are more vulnerable to depression than married females, but single females are more vulnerable to depression than single males. Married males reported higher frequencies than married females for both mild and moderate levels of depression. Single females