S.Naeem  ( Departments of Psychiatry and Community Health Sciences*, The Aga Khan University, Karachi. )
B.S. Ali  ( Departments of Psychiatry and Community Health Sciences*, The Aga Khan University, Karachi. )
A. Iqbal  ( Departments of Psychiatry and Community Health Sciences*, The Aga Khan University, Karachi. )
S. Mubeen  ( Departments of Psychiatry and Community Health Sciences*, The Aga Khan University, Karachi. )
A. Gul  ( Departments of Psychiatry and Community Health Sciences*, The Aga Khan University, Karachi. )

Different psychological techniques have an established place in treating anxiety and/or depression.1-3 The prognosis for recovery when such techniques are used is dependent on the relationship between certain personality traits and social variables.4 Physical ill health, bereavement and positive family history of depression are known to be associated with poor outcome.5 This paper explores the similarities and differences in the factors that facilitated or hindered recovery from anxiety and/or depression in women who had received counselling.

This paper is the qualitative arm of a conventional randomized controlled trial, which was conducted to see the effectiveness of community counselling by minimally trained counsellors in reducing the level of anxiety and/or depression in women from their own community. Through systematic sampling, 366 women with anxiety and/or depression were identified and randomly divided into an intervention and a control group. The instrument used to assess the levels of anxiety and/or depression was the Aga Khan University Anxiety and Depression Scale (AKUADS), an indigenous screening instrument, it has been developed from patients' symptoms as expressed in the local language Urdu, and has been validated keeping the psychiatrist's diagnosis (according to DSM III - R) as the gold standard. The cut-off for caseness is a score of 19 and above.6,7
Due to refusals and dropouts, only 70 women who had an initial AKUADS score of 19 and above, completed 8 counselling sessions from the intervention group. The counselling was mostly supportive with some problem-solving and cognitive-behavioral components, because use of cognitive and behavioral strategies by women recovering from depression has been reported.8 A statistically significant reduction in the post counselling scores was found in 59 women; 35 out of them were no longer anxious and/or depressed as their scores fell below 19 (Full recovery,
group I). Post counselling scores of 24 women showed a significant reduction from their initial scores but remained above 19
(Partial recovery; group II) while 10 women had worsening of their AKUADS scores (Worsened scores, group III).
Selection criteria of women for focus group discussions (FGDs) and in-depth interviews from the above groups was based on a positive or a negative change of 5 points or more in the post counselling AKUADS scores. For both groups I and II, FGD as well as in-depth interviews were conducted, however for group III, no FGD was conducted as only three women fulfilled the inclusion criteria of a change of 5 negative points.
The two FGDs were conducted at a welfare hospital located at the site of the study and in-depth interviews were conducted either at the participants' homes or at the hospital. Semi-structured guidelines were prepared for conducting FGDs and in-depth interviews with the intent to explore the perceptions and feelings of participants regarding counselling. In the FGDs besides a facilitator and an observer a rapporteur was also present. The FGDs and the in-depth interviews were audio-taped and the interviewers also took extensive notes. Average time for FGDs and interviews was about 1-1/2 hours. The investigators carried out all the FGDs and interviews, which were transcribed and documented. A content analysis of the data was done by the investigators independently and then notes were matched. The themes evolved after repeated analysis of the data were gathered.

Table 1. The attributes of women belonging to different FGDs and in-depth interviews. Qualitative tools Attributes Group 1Full recovery n=7 Group II Partial recovery n=7 Group III Worsensed Focus group discussion Age range 30-40 year 29-50 year No FGD was Marital status All married All married conducted because Numbre of Children 2-6 2-7 of less number of women in this group Educational status Only 5 were educated Only 1 were educated n=6 n=4 n=3 In-depth interviews Age range 23-40 year 21-48 year 30-40 year Marital status 5 married 3 married All married Numbre of Children 1-6 2-8(I had no child) 5-6 children Educational status All of them were educated Only 2 were educated Only 1 were educated

Table 2. Themes developed and their manifestation in the three groups. [(0)] [(1)] [(2)]

The sociodemographic characteristics of study subjects are given in table 1. The themes that emerged from the FGDs and the interviews are provided in table 2. The relevant quotes (given in italics) highlighting the similarities and differences (given in bold) between the three groups are provided. The verbatim (quotes) have been translated into English from originals that were expressed by the participants in the local language 'Urdu'. The level of severity of issues was determined by the number of times an issue was raised and the intensity with which it was expressed.

Table 1 demonstrates the beneficial effects of education. Education has been found to confer protection in many studies9-11 as it is known to improve coping mechanisms in more than one-way; it raises the self-efficacy and therefore the self-esteem of women. It also makes women feel less helpless in difficult situations and gives a greater sense of control over their environment.12
The relationship between causal and correlational factors is complex in psychiatry, but the risk factors that emerged from the FGDs / interviews were financial, health and relationship problems. The association between the above long-term difficulties and depression has been known for years.13,14 In a local study15 ongoing financial and relationship difficulties (particularly with husband and in-laws) were identified as risk factors for depression and this study confirms the same.
Strained relationships were a major problem and women from group III specially mentioned that their eldest sons who had not come up to their expectations of financial and emotional support had disappointed them.
The psychological impacts of violence and abuse are known to contribute to anxiety, depression and low self-esteem.16 All the groups reported verbal abuse; however, groups II and III also reported physical abuse. Low self-esteem though reported by both groups II and III was more severe in the latter leading to suicidal ideation as result of feelings of extreme worthlessness.
Minor health problems in group I did not obstruct recovery but the severe personal and family health problems did hinder recovery as found in groups II and III.
The association of religious involvement and spirituality with low levels of anxiety and depression is also known.17 The coping strategies used by our study subjects had a common theme of 'acceptance' and 'praying' (faith in God'). Other helpful themes that emerged were 'sharing easily with a stranger who was an attentive listener' (counsellor) and 'release of tension by sharing'.
All the groups were found to be using the "anger management skills" learnt, but the women from the full recovery group were using their cognitive-behavioral and problem - solving techniques much more effectively than the participants of the other two groups, and perceived the benefits of counselling as being more long lasting, while the women from group II felt the beneficial effects to be transitory.
The effectiveness of cognitive therapy in terms of improving psychological symptoms and social functioning has been reported18 and similar changes were observed in the women of group I in this study, while the women of the other two groups were mainly looking towards external sources of financial help to overcome their anxiety and/or depression.
AKUADS score of women from group III had increased but counselling was still perceived as beneficial. These women had severe personal physical health problems. AKUADS has 'somatic' and 'psychiatric' stems. Any increase in somatic symptoms would cause an increase in the total score even when psychiatric symptoms could have been reduced.
In order to make an impact on anxiety and/or depression which are emerging as major public health concern with a higher prevalence in women, large scale mental health promotion efforts including counselling, stress/anger management and violence prevention programs are required. However, to make such efforts effective, what is required is a major structural societal change ensuring equitable distribution of financial resources, access to health care and preventing abuse in families, as this is what will probably make a difference!

Financial problems, interpersonal difficulties, chronic health problems and adverse life events can precipitate/perpetuate depression or be a result of depression itself and it is difficult to decide which came first.

We wish to thank all the people of Qayoomabad, the administration of Qayoomabad welfare general hospital and our counsellors who helped us in conducting this project. We are also grateful to the University Research Council of Aga Khan University that gave us the required funds.

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