A Review on Assessment and Treatment for Depression in Malaysia

A Review on Assessment and Treatment for Depression in Malaysia
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  Hindawi Publishing CorporationDepression Research and TreatmentVolume 2011, Article ID 123642,8pagesdoi:10.1155/2011/123642 Review Article  AReviewonAssessmentand TreatmentforDepressioninMalaysia  FirdausMukhtar 1 andTianP.S.Oei 2 1 Department of Psychiatry, Faculty Medicine and Health Sciences, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia  2 School of Psychology and CBT Unit, Toowong Private Hospital, University of Queensland, Brisbane, Queensland 4072, Australia Correspondence should be addressed to Firdaus Mukhtar, Received 28 January 2011; Revised 10 May 2011; Accepted 9 June 2011Academic Editor: Harm W. J. van MarwijkCopyright © 2011 F. Mukhtar and T. P. S. Oei. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the srcinal work is properly cited.This paper aimed to review the literature on depression that focused on its assessment and treatment in Malaysia. PsycINFO,Medline, local journals were searched, and 18 published articles were included in this paper. Results indicate that research ondepression in Malaysia, particularly validation studies and psychotherapy research, was weak and fragmented, with minimalempirical evidence available. Pharmacotherapy still dominated the treatment for depression, and, in terms of psychotherapy,Cognitive Behavioural Therapy (CBT) was recently practiced, but only a few studies have reported on the treatment e ffi cacy of CBT. Major limitations of studies were noted, and, consequently, the problems that are associated with the implementation andfuture direction of clinical and research on depression in Malaysia were discussed. In short, the contribution of empirical researchon the assessment and treatment for depression remained inconsistent and fragmented and urgently in need of further empiricalinvestigation. 1.Introduction It is projected that depression, an a ff  ective disturbance, willbe among the leading causes of worldwide disability, by the year 2020 [1]. Across the Asia-Pacific region, rates of currentor 1-month major depression ranged from 1.3 to 5.5% andrates of major depression in the previous year ranged from1.7 to 6.7% [2]. Malaysia is no exception; in fact, depressionis the most commonly reported mental illness in Malaysia.Depression is by far the most important and treatable con-dition and is projected to a ff  ect approximately 2.3 millionMalaysians at some point in their lives [3]; yet depressionremains underdetected and undertreated [4].Theories of psychological disorders (particularly depres-sion) are both clear and abundantly found in the literature.These theories can be broadly classified into either biologicalor psychosocial. Pharmacological theories of depression,such as amine dysregulations, are well established [5,6] and thus provide a strong foundation for the pharmacologicaltreatment of depression. It is clear that the e ffi cacy of antide-pressants, such as Selective Serotonin Reuptake Inhibitors(SSRI) and tricyclics, are well documented [7,8]. Similarly, psychological theories such as Beck’s cognitive theories arewell articulated and generally accepted in the West [9–11]. It is also generally accepted in the literature that Cogni-tive Behaviour Therapy (CBT) is an e ff  ective way of treatingdepression [12–15]. InMalaysia,biologicaltheories,and,thus,thepharmaco-logical treatment of depression, are commonly used in clin-ical practices in community settings and hospitals; in fact,this is the main form of treatment for depression in Malaysia[16].Unsurprisingly,thedevelopmentofpsychotropicmedi-cation in Malaysia has tended to ignore psychological aspectsin the process of disease recognition and understanding, par-ticularly for depression [4]. While psychotherapies for thetreatmentofdepressionareappliedclinicallyinMalaysia,itisunfortunate that no empirical evidence to support such usehas been established. Further, it is still unknown whetherpsychological instruments for the assessment of depressionand the theories for depression are valid and reliable for usein Malaysia.  2 Depression Research and TreatmentSince psychological theories and, thus, treatment aremore susceptible to cultural influences, it is therefore im-portant to establish the validity of Western-derived psycho-logical theories and psychological instruments for use in thetreatment of depression in di ff  erent cultures, such as Malay-sia [17,18]. Therefore, the aims of this paper were to review available articles related to the issues of assessment andtreatment for depression. 2.Method  2.1. Selection of Studies. A search of the literature using elec-tronic databases for PsycINFO and Medline (1970–present)was conducted (see Figure1). Due to the scarcity of papersfound in electronic databases, this paper also included man-ual searches of all available local journals in Malaysia, suchas the Malaysian Journal of Psychiatry, the ASEAN Journal of Psychiatry, and the Journal of Malaysian Medical and HealthScience, in order to meet the objective of this paper.The search was refined to identify studies published inEnglish over the last 30 years that included at least a cross-sectional and experimental study of depression using adultparticipants. Adult studies were targeted, in order to elimi-nate developmental di ff  erences in child or adolescent groups.Meta-analysis cannot be done due to the limited number of samples, variability of instruments used to measure depres-sion, and insu ffi cient reports on the statistical parts that arerequired for a systematic review. The publication years werechosen to incorporate the majority of studies, since the treat-ment for depression has been designed and researched.Searcheswereconductedusingthekeywords,assessment,treatment, and Malaysia; and the following words in the title:depression, depressive disorder, and mood disorder. Thesekeywords and title words were selected based on those foundin the majority of papers collected earlier during the reviewprocess. Treatment keywords were combined to yield 425citations in PsycINFO and 325 citations in Medline. The as-sessment terms were combined to produce 26 citations inPsycINFOand28citationsinMedline.Studieswereexcludedfor the following reasons: biological/physiological studiesratherthantreatment/assessmentstudies,depressionwasnotthe target of treatment, stress was misinterpreted as depres-sion, and the article was a discussion of historical data rath-er than empirical studies.This review process cannot exclude papers with no in-formation on e ff  ect size, as that would lead to a limited num-ber of papers to review. This process resulted in 12 studiesthat were suitable for the review. An additional six studiestaken from local journals, which met the selection criteria,were cited in these articles and added to the review, resultingin a total of 18 studies.  2.2. Description of Studies Reviewed. The assessment studies,arrangedbytheiryearofpublication,arepresentedinTable1(a key of abbreviated terms is shown below the table).The following study features are summarised in Table1: (a)study number and reference, (b) the target group, (c) thetotal number of participants, (d) representative of ethnicity, 26 citations in PSYCINFO and 28 citationsin MedlineExclude studies not related toassessment and treatment yield to 12studiesCombine articles with 6 articles found inlocal journals yield to 18 articles toreviewCombine assessment term and titlewords; combine treatment term andtitle wordsInsert keywords: assessment, treatment,Malaysia and title words: depression,depressive disorder, mood disorderSearch articles via PsycINFO, Medline425 citations in PsycINFO and 325 inMedline Figure 1: Flowchart of searching articles to review. (e) gender, (f) measures used, (g) value of Cronbach’s α , (h)validity study conducted, and (i) whether Exploratory FactorAnalysis or Confirmatory Factor Analysis is conducted. Thedescriptor“targetgroup”wasincludedtoinvestigatewhetherthe assessment for depression was targeting patient or non-patient samples. The sample size is important, since largersamples are known to give more reliable and representativeresults than small sample sizes ( n < 30). The ethnicity andgender are important, because Malaysia is a multiethnic so-ciety; whereas, for gender, female is the most researched gen-der reported in studies worldwide. In order to investigatewhether the instruments used to measure depression arevalidated with study on reliability and validity, the last threecategories are importantly shown in the review.Meanwhile, for treatment studies, Table2summarizes allpapers that were included in this review process. The fol-lowing study features are summarised in Table1: (a) study number and reference, (b) the sample and problem for treat-ment (depression symptoms or disorder), (c) ethnicity cat-egories,(d)gender,(e)designofstudy,(f)interventiontypes,(g) the duration of intervention, (h) measures used, and (i)treatment outcome. The descriptor “problem for treatment”was included to investigate whether treatment was targeting  Depression Research and Treatment 3 Table 1: Studies on the assessment of depression in Malaysia.Study Target group n Ethnicity (%)Gender( n or %)Measure Cronbach’s ( α ) Validity EFA/CFA(1) Quek et al.[19]Urological 237MalaysChinese(majority)IndianNA BDIInternal Rel.(0.56–0.87);test-retest(0.56–0.87)Discriminant;specificity andsensitivity NA(2) Azah et al.[20]Primary care 265 Malays (100)Male ( n = 101)Female( n = 164)PHQ-9,HDRS,HADSInternal Rel.(0.67);test-retest(0.73)Concurrent;specificity andsensitivity NA(3) Oei andMukhtar [21]Students, generalcommunity, primary care, and depressedpatients1050 Malays (100)Male ( n = 270)Female( n = 820)ATQ,BDI,DASInternal Rel.(0.90)Concurrentanddiscriminant;specificity andsensitivity EFA/CFA(4) Mukhtar andOei [22]Students, generalcommunity, primary care, and depressedpatients1050 Malays (100)Male ( n = 270)Female( n = 820)BDI,ATQ,DASInternal Rel.(0.90)Concurrentanddiscriminant;specificity andsensitivity EFA/CFA(5) Ramli et al. Patients with diabetes 153Malays (12)Chinese (16)Indian (17)Male (75)Female (78)DASS-21Internal Rel.(0.74–0.79)Construct CFA(6) Mukhtar andOei [23]Students, generalcommunity, primary care, and depressedpatients ( n = 113)1050 Malays (100)Male ( n = 270)Female( n = 820)DAS,BDI,ATQInternal Rel.(0.82)Concurrentanddiscriminant;specificity andsensitivity EFA/CFA(7) Ramli et al.Patients at Infertility Centre246Malays (230)Chinese (7)Indian (6)Others (3)Male (123)Female (123)DASS-21,HADSInternal Rel.(0.81–0.83);test-retest(0.82–0.84)Concurrent NA Note: Key to measure: (ATQ): Automatic Thoughts Questionnaire; (BDI): Beck Depression Inventory; (DAS): Dysfunctional Attitude Scale; (DASS-21):Depression Anxiety Stress Scale-21; (HARS): Hamilton Anxiety Rating Scale; (HDRS): Hamilton Depression Rating Scale; Hospital Anxiety and DepressionScale; (PHQ-9): Malay Version of Brief Patient Health Questionnaire; n = No. of subjects. patients with major versus minor depression, secondary de-pression, or depression symptoms. The sample size is impor-tant,sincelargersamplesareknowntogivemorereliableandrepresentative results than small sample sizes ( n < 30). Inter-ventiontypesareimportant,inordertoinvestigatedominanttreatments sought or reported to overcome depression,whilst the duration and number of hours of interventionwere included to give an understanding on the e ff  ectivenessof intervention related to time and cost. Finally, the type of outcome used to measure depression is important to investi-gate the reliability and validity of the tools used to assess de-pression and the treatment outcome. 3.Results 3.1. Description of Studies Included in the Review. A total of 18 studies fulfilled the above criteria for inclusion. Of these,seven studies were psychometric validation of a depressioninstrument and 11 studies were for treatment outcome of depression (Table2). A total of 2,501 participants were repre-sented, with sample sizes ranging from 1 (Studies 8, 12, and15) to 1,050 (Studies 3, 4, and 6). A diversity of ethnicitieswere represented, where Malays were the dominant ethnicity involved in research (Studies 2, 3, 4, 6, 11, 12, 14, 15, and 18;only Malay subjects). The majority of studies (80%) involvedparticipants who met research diagnostic criteria or DSMcriteria for unipolar depressive disorders, while the remain-der examined depression symptoms in participants drawnfrom at-risk groups in the community. In terms of gender,female subjects ( n = 1279) participated the most in re-search for depression, but several studies did not report thiscategory (Studies 1, 11, 13, 14, and 17). 3.2. Assessment Used to Measure Depression. In a review onassessments used to measure depression, three aspects will bediscussed: subjects, measures used, and the statistical meth-od. Table1showsvalidation studieson measuresusedforde-pression reported between 2001 and 2011. The range of sub- jectsparticipatedinthesevalidationstudiesinclude students,general community, and patients (urological, primary care,psychiatric, diabetes, and infertility). The number of partici-pants involved in these validation studies ranges from 237 to  4 Depression Research and Treatment        T     a    b    l    e     2   :    S    t   u    d    i   e   s   o   n    t    h   e    t   r   e   a    t   m   e   n    t   o    f    d   e   p   r   e   s   s    i   o   n    i   n    M   a    l   a   y   s    i   a .    S    t   u    d   y    D    i   s   o   r    d   e   r   o   r   p   r   o    b    l   e   m    E    t    h   n    i   c    i    t   y    (       n     )    G   e   n    d   e   r    (       n     )    D   e   s    i   g   n    I   n    t   e   r   v   e   n    t    i   o   n    D   u   r   a    t    i   o   n   o    f    t   r   e   a    t   m   e   n    t    O   u    t   c   o   m   e   m   e   a   s   u   r   e    T   r   e   a    t   m   e   n    t   r   e   s   u    l    t    (   +   v   e    /    −    v   e    )    (    8    )    W   o   o   n   a   n    d    T   e   o    h    [    2    4    ]    D   e   p   r   e   s   s    i   o   n   w    i    t    h    h   y   s    t   e   r    i   c   a    l   p   e   r   s   o   n   a    l    i    t   y    d    i   s   o   r    d   e   r    C    h    i   n   e   s   e    (       n     =     1    )    F   e   m   a    l   e    (       n     =     1    )    C   a   s   e   s    t   u    d   y    P   s   y   c    h   o    d   y   n   a   m    i   c    t    h   e   r   a   p   y   a   n    d   a   m    i    t   r    i   p    t   y    l    i   n   e    1   y   e   a   r   a   n    d    5   m   o   n    t    h   s    N    A    P   o   s    i    t    i   v   e    (    9    )    O   n   g   a   n    d    L   e   e    [    2    5    ]    D   e   p   r   e   s   s    i   v   e   n   e   u   r   o   s    i   s   a   n    d   m   a   n    i   c    d   e   p   r   e   s   s    i   v   e    M   a    l   a   y    (       n     =     9    )    C    h    i   n   e   s   e    (       n     =     6    )    I   n    d    i   a   n    (       n     =     2    )    M   a    l   e    (       n     =     6    )    F   e   m   a    l   e    (       n     =     1    1    )    R    C    T    N   o   m    i    f   e   n   s    i   n   e   a   n    d   a   m    i    t   r    i   p    t   y    l    i   n   e    9   w   e   e    k   s    H    D    R    S   ;    G    l   o    b   a    l   c    l    i   n    i   c   a    l   p   a   r   a   m   e    t   e   r    P   o   s    i    t    i   v   e   w    i    t    h    f   e   w   a    d   v   e   r   s   e   e       ff    e   c    t   s    (    1    0    )    I   n    d   r   a   n    [    2    6    ]    D   e   p   r   e   s   s    i   o   n    (    1    2    )    D   y   s    t    h   y   m    i   a    (    3    )    A   n   x    i   e    t   y    (    3    )    B    i   p   o    l   a   r    (    1    )    S   c    h    i   z   o   p    h   r   e   n    i   a    (    1    )    (    O   u    t   p   a    t    i   e   n    t    )    M   a    l   a   y   s    (       n     =     4    )    I   n    d    i   a   n    (       n     =     5    )    C    h    i   n   e   s   e    (       n     =     8    )    O    t    h   e   r   s    (       n     =     3    )    M   a    l   e    (       n     =     9    )    F   e   m   a    l   e    (       n     =     1    1    )    R    C    T    M   o   c    l   o    b   e   m    i    d   e    6   w   e   e    k   s    H    D    R    S   ;    C    G    I   ;    P    G    I    P   o   s    i    t    i   v   e   w    i    t    h    f   e   w   a    d   v   e   r   s   e   e       ff    e   c    t   s    (    1    1    )    A   z    h   a   r   a   n    d    V   a   r   m   a    [    2    7    ]    D   e   p   r   e   s   s    i   o   n    M   a    l   a   y   s    (       n     =     6    4    )    N    A    R    C    T    R   e    l    i   g    i   o   u   s   p   s   y   c    h   o    t    h   e   r   a   p   y   +   s   u   p   p   o   r    t    i   v   e    t    h   e   r   a   p   y    1    5  –    2    0   s   e   s   s    i   o   n   s    H    D    R    S    P   o   s    i    t    i   v   e    (    1    2    )    R   a   z   a    l    i    [    2    8    ]    D   e   p   r   e   s   s    i   o   n    M   a    l   a   y    (       n     =     2    )    M   a    l   e    (       n     =     1    )    F   e   m   a    l   e    (       n     =     1    )    C   a   s   e   s    t   u    d   y    D   o    t    h    i   e   p    i   n   a   n    d   m   a   p   r   o    t    i    l    i   n   e    3   m   o   n    t    h   a   n    d    1   m   o   n    t    h    N    A    P   o   s    i    t    i   v   e    (    1    3    )    R   a   z   a    l    i   e    t   a    l .    [    2    9    ]    D   e   p   r   e   s   s    i   o   n    (       n     =     1    0    0    )   a   n    d   a   n   x    i   e    t   y    (       n     =     1    0    3    )    M   a    l   a   y   s    (       n     =     2    0    3    )    N    A    R    C    T    R   e    l    i   g    i   o   u   s   p   s   y   c    h   o    t    h   e   r   a   p   y   +   s   u   p   p   o   r    t    i   v   e    t    h   e   r   a   p   y   +    b   e   n   z   o    d    i   a   z   e   p    i   n   e   s   o   r   a   n    t    i    d   e   p   r   e   s   s   a   n    t   s    2    6   w   e   e    k   s    H    A    R    S   ;    H    D    R    S    P   o   s    i    t    i   v   e    (    1    4    )    R   a   z   a    l    i   a   n    d    H   a   s   a   n   a    h    [    3    0    ]    D   e   p   r   e   s   s    i   o   n    (    O   u    t   p   a    t    i   e   n    t    )    M   a    l   a   y    (       n     =     8    2    )    N    A    R    C    T    A   m    i    t   r    i   p    t   y    l    i   n   e ,    i   m    i   p   r   a   m    i   n   e ,    d   o    t    h    i   e   p    i   n   a   n    d   m   a   p   r   o    t    i    l    i   n   e    8   w   e   e    k   s    H    D    R    S    P   o   s    i    t    i   v   e    (    1    5    )    R   a   z   a    l    i    [    3    1    ]    M   a   s    k   e    d    D   e   p   r   e   s   s    i   o   n    (    O   u    t   p   a    t    i   e   n    t    )    M   a    l   a   y    (       n     =     1    )    F   e   m   a    l   e    (       n     =     1    )    C   a   s   e    S    t   u    d   y    D   o    t    h    i   e   p    i   n    6   w   e   e    k   s    N    A    P   o   s    i    t    i   v   e    (    1    6    )    N   g   a   n    d    S    t   e   v   e   n   s    [    3    2    ]    D   e   p   r   e   s   s    i   o   n    M   a    l   a   y   s    i   a   n    C    h    i   n   e   s   e    (       n     =     1    3    )   ;   o    t    h   e   r   s    (       n     =     3    2    )    M   a    l   e    (       n     =     6    )    F   e   m   a    l   e    (       n     =     8    )    R    C    T    S   e   r    t   r   a    l    i   n   e    (    S    S    R    I    )    6   w   e   e    k   s    H    D    R    S   ;    C    G    I   ;    L    U    N    S    E    R    S   ;    P    l   a   s   m   a   m   e   a   s   u   r   e   m   e   n    t    P   o   s    i    t    i   v   e   w    i    t    h    f   e   w   a    d   v   e   r   s   e   e       ff    e   c    t   s    (    1    7    )    A   z    h   a   r   e    t   a    l .    D   e   p   r   e   s   s    i   o   n    (    O   u    t   p   a    t    i   e   n    t    )       n     =     9    6    N    A    R    C    T    C    B    T   +    E    S    C    C    B    T   +    S    T    R    C    B    T   +    F    X    T    1    2   w   e   e    k   s    H    A    D    S   ;    B    D    I   ;    W    H    O  -    Q    O    L    P   o   s    i    t    i   v   e   ;    C    B    T   +    E    S    C   s    h   o   w    b   e    t    t   e   r    (    1    8    )    M   u    k    h    t   a   r   e    t   a    l .    [    3    3    ]    D   e   p   r   e   s   s    i   o   n    (    O   u    t   p   a    t    i   e   n    t    )    M   a    l   a   y   s    (       n     =     1    1    3    )    M   a    l   e    (       n     =     5    1    )    F   e   m   a    l   e    (       n     =     6    2    )    R    C    T    G    C    B    T   +    T    A    U    T    A    U    8   s   e   s   s    i   o   n   s   ;    1   m   o   n    t    h    A    T    Q   ;    D    A    S    P   o   s    i    t    i   v   e   a   n    d   m   a    i   n    t   a    i   n   e    d   a    t    3   a   n    d    6   m   o   n    t    h    f   o    l    l   o   w   u   p   s     N   o    t   e   :    K    E    Y    t   o    i   n    t   e   r   v   e   n    t    i   o   n    (   a    l   p    h   a    b   e    t    i   c   a    l   o   r    d   e   r    )   :    G   r   o   u   p    C   o   g   n    i    t    i   v   e    B   e    h   a   v    i   o   u   r    T    h   e   r   a   p   y    (    G    C    B    T    )   ;    S   e    l   e   c    t    i   v   e    S   e   r   o    t   o   n    i   n    R   e   u   p    t   a    k   e    I   n    h    i    b    i    t   o   r    (    S    S    R    I    )   ;    E   s   c    i    t   a    l   o   p   r   a   m    (    E    S    C    )   ;    S   e   r    t   r   a    l    i   n   e    (    S    T    R    )   ;    F    l   u   o   x   e    t    i   n   e    (    F    X    T    )   ;    T   r   e   a    t   m   e   n    t  -   a   s  -    U   s   u   a    l    (    T    A    U    )    N   o    t   e   :    K    E    Y    t   o   m   e   a   s   u   r   e   s    (   a    l   p    h   a    b   e    t    i   c   a    l   o   r    d   e   r    )   :    A   u    t   o   m   a    t    i   c    T    h   o   u   g    h    t   s    Q   u   e   s    t    i   o   n   n   a    i   r   e    (    A    T    Q    )   ;    B   e   c    k    D   e   p   r   e   s   s    i   o   n    I   n   v   e   n    t   o   r   y    (    B    D    I    )   ;    C    l    i   n    i   c   a    l    G    l   o    b   a    l    I   m   p   r   e   s   s    i   o   n    (    C    G    I    )   ;    D   y   s    f   u   n   c    t    i   o   n   a    l    A    t    t    i    t   u    d   e    S   c   a    l   e    (    D    A    S    )   ;    H   a   m    i    l    t   o   n    A   n   x    i   e    t   y    R   a    t    i   n   g    S   c   a    l   e    (    H    A    R    S    )   ;    H   a   m    i    l    t   o   n    D   e   p   r   e   s   s    i   o   n    R   a    t    i   n   g    S   c   a    l   e    (    H    D    R    S    )   ;    L    i   v   e   r   p   o   o    l    U   n    i   v   e   r   s    i    t   y    N   e   u   r   o    l   e   p    t    i   c    S    i    d   e  -   e       ff    e   c    t    R   a    t    i   n   g    S   c   a    l   e    (    L    U    N    S    E    R    S    )   ;    P   a    t    i   e   n    t   s    G    l   o    b   a    l    I   m   p   r   o   v   e   m   e   n    t    (    P    G    I    ) .  Depression Research and Treatment 51,050subjects.Meanwhile,intermsofethnicity,Malaysformthe majority that have been involved in validation studies inMalaysia. In terms of gender, females ( n = 1185) and males( n = 569) have been investigated; however, gender was notreported in Study 1.In terms of measure, four studies (Studies 1, 3, 4, and6) [19,21–23] used the Beck Depression Inventory (BDI), followed by DASS-21 (Studies 5 and 7) [34,35], and PHQ- 9, HDRS and HADS (Study 2) [20]. Significantly, in Westernstudies, the BDI has been established as the most commonly used outcome measure either in a clinical setting or inresearch on depression [6]. Nevertheless, recent studies [22] support the notion that the BDI can be used as an instru-ment with confidence to measure levels of depression symp-tomsinMalaysians.Interestingly,tworecentstudiesincludedcognitive measures (ATQ and DAS) for depression (Studies 3and 6). These instruments are important because the cog-nitive behavioural approach emphasises alleviating negativecognitions in the treatment of depression.Meanwhile, in terms of statistical analyses, both internalreliability and validity analyses were mentioned in all studies.Specifically, BDI studies have reported Cronbach’s alpha be-tween 0.56 to 0.90 and test-retest realibility (0.56–0.87).Meanwhile, for DASS-21, Cronbach’s alpha and test-retestreliability are between 0.74–0.83 and 0.82–0.84, respectively.In addition, for the PHQ-9, HDRS and HADS, their Cron-bach’s alpha is 0.67 and test-retest reliability is 0.73. Mean-while, Cronbach’s α for ATQ is 0.90 and DAS is 0.82. For va-lidity analyses, a combination of discriminate, concurrent,construct, and concurrent validities has been reported. Sev-eral studies also included specificity and sensitivity analysisto discriminate whether the tool is suitable to detect symp-toms between medical and nonmedical populations. For anassessment to have robust and strong psychometric proper-ties, Exploratory Factor Analysis and Confirmatory FactorAnalysis are recommended, in order for a measure to be usedasavalidtool.Now,onlyrecentStudies3,4,5,and6reportedvalues on EFA and CFA, which has been shown to be at anacceptable range.To sum up this section, the above showed that two in-struments for assessment of symptoms of depression hadgood valid and reliable psychometric information and thuscan be used with some confidence for clinical research.OtherssuchasPHQ-9,HDRS,andHADShaveminimal psy-chometric validation information and thus must be usedwith caution. 3.3. Treatment Outcome of Depression in Malaysia. A reviewon treatment of depression that has been reported inMalaysia includes two general approaches (a) pharmacother-apy and (b) psychotherapy.Eight of the 12 studies used randomised controlled trial(RCT) type of research design, while three studies (Studies 8,12, and 15) used case studies design. In terms of duration of treatment, all studies from 1976 to 2007 completed the inter-vention between 6 weeks and 17 months, but recent studiesreportedsimilarsignificantoutcomecompletedtheinterven-tion in 4 weeks for 8 sessions of Group CBT approach. Themajority of treatment studies (see Table2) in Malaysia wereusing HDRS as outcome measure, but recent study (17) wasusing BDI instead. The only study that used cognition mea-sures was Study 18 that emphasises on cognitive behaviouralapproach of assessment and intervention.In terms of subjects that have undergone treatment re-search of depression in Malaysia, both Malays and female arethe dominant ethnic and gender that have been mostly re-searched. Only Studies 9, 10, and 16 were combining all threeethnic groups in Malaysia, otherwise other studies reportedsubjects and were only among Malays. (a) Pharmacotherapy. Table2lists studies reported on theusage of pharmacotherapy intervention such as Amitripty-line (Studies 8, 9, and 14), Nomifensine (Study 8), Moclobe-mide (Study 10), Dothepin (12, 14, and 15), Maprotiline(12 and 14), Benzodiazepines (13), Imipramine (Study 14),Sertraline (16 and 17) Escitalaporam (17), and Fluoxetine(17).Among all studies on pharmacotherapy, four studies(Studies 9, 10, 14, and 16) [25,26,30,32] were using RCT method of research design. All four studies were using pa-tients with depression, except Study 10 which included otherdiagnosis as well besides depression such as anxiety, bipolar,and schizophrenia. In terms of duration of treatment, mostoftheRCTstudiesforpharmacotherapycompletedthestudy around the same time that range between six weeks and 9weeks, and all four studies were using Hamilton DepressionRating Scale as an outcome measure before the Beck De-pression Inventory and Depression Anxiety Stress Scale werevalidated in the country.Besides RCT studies, interesting findings were from twocase studies using two (Study 12) and one (Study 15) Malay patients with major depression who attributed their present-ing symptoms to witchcraft or possession by evil spirits [28,31]. These three patients were given dothiepin and mapro-tiline, respectively. Razali concluded from this report that,although patients were depressed before they went to see the bomoh (traditional healer),thespecificpsychosomatic symp-toms developed after the bomoh convinced the patients thatthey had been charmed or their superstitious beliefs hadbeen reinforced. They both improved slowly and were ableto resume work 3 months and 6 weeks later.Although Razali and Hasanah [16] stated that phar-macotherapy treatment for depression can be coste ff  ective,there still remains an absence of any systematic treatmentevaluation yet to conclude if the treatment is coste ff  ective toall patients from both rural and urban regions. (b) Psychotherapies. Besides pharmacological treatment, pa-tients also have the alternative choice of psychotherapy treatments to treat symptoms of depression; several studies[13–16] support that a combination of pharmacotherapy  and psychotherapy yields a better outcome.In this paper, four types of psychotherapies have been re-ported such as psychodynamic (Study 8) [24], religious psy-chotherapy (Studies 11 and 13) [27,29], supportive psycho- therapy (Studies 11 and 13), individual cognitive behaviour
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