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Original Article
Taiwanese Journal of Psychiatry (Taipei) Vol. 24 No. 1 2010
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Factors Associated with Depressive Symptoms among Soldiers Ting-Hung Hsieh, M.D., Kuo-Jung Chang, M.D., Wen-Kuei Lee, M.D., Yu-Chi Ku, M.D., Objective: The aims of this study was to investigate the prevalence of depressive symptoms among soldiers during military training, and to further evaluate and analyze factors associated with depressive symptoms. Methods: In this cross-sectional study, the Taiwanese Depression Questionnaire (TDQ) was given to assess the self-reported experiences of depressive symptoms among 1,155 young adult soldiers. All male subjects were non-randomized selected from the army troops in northern Taiwan, and completed general training. We divided them into the“low depressive symptoms group”and the“high depressive symptoms group,” based on TDQ screening results. The cut-off point was 19. Results: The findings showed that 27.7% (n=320) of the soldiers had TDQ scores more than or equal to 19. With logistic regression, we found that significant correlations between depressive symptoms, and factors of low education levels, low family income, stress from military life and family, high levels of financial stress, stress from worrying about the future, passive coping skills, and inadequate social support. Conclusions: This pilot study revealed a higher prevalence rate of depressive symptoms and may reflect problems in adapting to military environment. Special attention should be paid in soldiers who have low education levels, low family income, stressors, passive coping skills, and inadequate social support during training course. Key words: soldiers, depressive symptoms, stress, social support (Taiwanese Journal of Psychiatry [Taipei] 2010;24:51-60)
Introduction The military is a restricted, controlled environment in which soldiers are exposed to stress. Inherent in military training composes of multiple sources of stress, including dramatic changes in living arrangements, separation from normal
sources of social support, and intense physical and emotional challenges. One study showed a higher than expected rate of depression in entry-level military personnel undergoing training [1]. Depression is a serious health problem in the military worldwide. Some studies have been reported a correlation with depression and such factors as service time [2], educational levels [3], smoking
Beitou Armed Forces Hospital Received: September 3, 2009; revised: October 12, 2009; accepted: November 24, 2009 Address correspondence to: Dr. Kuo-Jung Chang, Beitou Armed Forces Hospital, No.60, Hsin-Ming Road, Beitou, Taipei 11243, Taiwan
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Factors Associated with Depressive Symptoms
[4-6], drinking [7], family structure [8, 9], parental relationships [10, 11], family income [12], and family history of depression [13, 14]. Stressors are also found to be correlated with depression. They include the military [1, 15], family [16], love relationship [17], finances [18], worrying about the future [16], poor coping skills [19-22], and inadequate social support [23-25]. Depression is recognized as a major public health problem in Taiwan. The Taiwanese health authority spends an annual average of US$116.6 million to treat depression [26]. In another study, 20.1% of urban elders and 12.8% of rural samples have been classified with depressive symptoms in Taiwan [27]. Various studies conducted on the prevalence of depressive symptoms showed that depressive symptoms are higher among soldiers. A study carried out in the Turkish army using the Beck Depression Inventory (BDI) was found that 29.9% of recruits have depressive symptoms [28]. Another study conducted on 443 navy recruits has been reported that 45% of them have depressive symptoms [13]. A similar study has been reported that 25.2% of soldiers undergoing military training experience depressive symptoms in China [2]. But up till now, few studies in Taiwan have been conducted on the prevalence of depressive symptoms among young adults during military training. Young men aged 18 years or older are required to serve in the military by law in Taiwan. Consequently, more than 100,000 young adult males enter the military each year. The aims of this study were to investigate the prevalence of depressive symptoms among soldiers during military training, and to further evaluate and analyze factors associated with depressive symptoms.
Methods Subjects and setting To determine the prevalence and nature of depressive symptoms among young adult males during military training, this research project was approved by Beitou Armed Forces Hospital and Medical Affairs Bureau, Ministry of National Defense and assigned authorization number 0940008716. We collected data from January 1, 2006 to December 31, 2007. The survey contained a sample of all soldiers during military training. Among which, 1,239 participants were male soldiers and non-randomly selected from army troops in northern Taiwan. We chose the northern area of Taiwan because the troops were relatively closer to our study site and they had already completed general military training at the training center. Then they were randomly distributed to the troops from every region of Taiwan by Ministry of National Defense, who were receiving training and agreed to undergo a psychological assessment. The targeted subjects had to meet the following inclusion criteria: males, who were 18years old or older, not suffered from any neurological, acute physical illnesses, or other impairments. We gave qualified individuals Taiwanese Depression Questionnaire (TDQ) and an additional questionnaire with socio-demographic characteristics. Comprehensive information of the study was provided to explain it in detail. Excluded individuals who were uncooperative or who could not understand the questionnaire, and 84 subjects who did not fill out the forms inadequately. At the end, 1,155 subjects (90.4% of the recruits) were included in the analyses.
Hsieh TH, Chang KJ, Lee WK, et al.
Instrument Different cultures use various methods for screening questionnaires for depression or assessment of mental disorder [29]. The TDQ is a culturally relevant questionnaire commonly used to survey target groups based on depressive characteristics among Taiwanese [30-32]. In consideration of culture bias in case identification, it adopted common idioms of emotional expression among contemporary Taiwanese for its item construction. Thus, Dr. Y. Lee developed a culturesensitive depression screen questionnaire. The validity by sensitivity, and specificity with the optimal cutoff of 19 to screen depressive symptoms were 0.89 and 0.92 [33]. The TDQ consisted of three dimensions, with a total of 18 items on a four-point rating scale ranging from “less than 1 day per week” (0) to “5 to 7 days per week” (3). The total score range is from 0 to 54. Examples of items on the scale included “How often did you feel blue and depressed during the past week?” and “How often did you have trouble in sleeping during the past week?” and “How often did you feel sick (headache, dizziness, palpitation, abdominal distress) during the past week?”
The procedure Before administering the questionnaires, we trained military officers on how to fill out the forms. The military officers were assigned to administer the questionnaire forms to the soldiers. It was done when soldiers were gathered in the quiet field. They were assured that their information would remain confidential and not be released. They were asked to answer the questions themselves without disclosing their names on the forms. During the administration, none of the commanders of the soldiers were present on the field. Subjects who could not understand the ques-
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tionnaires were excluded from the study. During the study, they simply distributed the forms to literate respondents, and trained research assistants collected the completed forms for analyses.
The statistical analysis We used descriptive statistics to describe the characteristics of participants and the distribution of TDQ scores. Samples were identified under the category of either the “low depressive symptoms group” or the “high depressive symptoms group” based on the TDQ screening results with the cutoff point at 19. Variables in this study included individual and familial socio-demographic features, stressors, coping skills, and social support. Between-group variances in categorical correlates were determined using chi-square. Multivariate logistic regression analysis was done to evaluate factors related to depressive symptoms. All statistical analysis was performed using Statistics Package for Social Sciences version 12.0 (SPSS, Inc., Chicago, Illinois, USA). Differences between groups were considered significant if p-values were less than 0.05.
Definitions used in the study The type of depression was not diagnosed, but the prevalence of depressive symptoms was investigated. TDQ item points of every participant were added and those reaching 19 point or more were accepted as the “high depressive symptoms group.” Alcohol consumption at least one glass per month was accepted as drinking. Low family income was defined as an average monthly income of less than NT$30,000 for a family. Non-two-parent family was grouped according to only one or no parents.
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Stressors included five main parts and whether the participants once suffered strong psychological stress during training, and subjective feeling of stress from military (such as maladjustment to military life), stress from one’s family (such as frequent conflicts with family members), stress from love relationship (such as instability in relationship), stress from finance (such as debts), and stress from worrying about the future (such as anxiety about finding a job after completing military service). Coping skills were categorized as passive and active. Examples of passive coping skills included avoidance, substance use, and aggressive behavior. Examples of active coping skills included physical activity, exercise, talking to someone, listening to music, and praying. Having one or several close friends and good relations with family members, leaders and colleagues were regarded as having good social support and environment conductive to good interpersonal relations.
Results Table 1 lists the characteristics of the study participants and their TDQ scores. Table 2 lists the correlated factors relating to depressive symptoms in multivariate logistic regression. A total of 1,155 subjects was enrolled in this study. The mean age was 22.8±2.9 years.
Discussion Some published studies describe the development of valid and reliable instruments for screening people with depression [34-36]. As previously mentioned, the TDQ is not used to diagnose depression, but to detect depressive symptoms. The TDQ Index has been widely used to
evaluate depressive symptoms in medically ill patients and the general population in Taiwan. In one study, depression has been measured using the TDQ in 108 chronic stable hemodialyzed patients [30]. In another study, investigators assessed the degree of depressive symptoms with TDQ on community-dwelling elderly in Taiwan [31]. In a recent study, the TDQ has been shown to be superior to the BDI in detecting depression in patients with chronic pain in Taiwan [32]. In our study, the TDQ showed that 27.7% of soldiers during military training had depressive symptoms (Table 1). The higher prevalence of depressive symptoms may reflect problems in adapting to the military, an environment that differs significantly from environments where subjects used to live in before the military service. Previous studies showed that service time, education levels, smoking and drinking are associated with the presence of depressive symptoms [2-7]. In our study a significant difference was not found between the groups with different service time (Table 1), perhaps because nowadays the military places more importance on the physical workload and mental stress of new recruits and were given more support and shown more care. The participants also all completed general training at training center. In comparisons of between groups in this study, participants in the “high depressive symptoms group” had significantly lower educational levels, consumed more than one pack of tobacco per day, and drank more compared to those in the “low depressive symptoms group (Table 1).” When all of the above variables were taken into consideration in the multivariate logistic regression analysis, the findings showed that individuals with low education levels (≦9 years) tended to be “high depressive symptoms group” at a rate 2.03 times higher than those that high education level(＞12 years) (Table 2). Lower level of
Hsieh TH, Chang KJ, Lee WK, et al.
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Table 1. Characteristics of the study group and their Taiwanese Depression Questionnaire scores Socio-demographic characteristics Total service time (months) ＜3 3-12 ＞12 Education level (years) ≦9 9-12 ＞12 Tobacco consumption (per day) More than one pack Less than one pack Doesn’t smoke Drinking Yes No Family structure Non-two-parent family Parents family Parental relationships Poor Fair Good Family income Low Not low Family history of depression Yes No Military stress Yes No Family stress Yes No Love relationship stress Yes No Financial stress Yes No Stress from worrying about future Yes No Coping skills Passive Active Social support Adequate Inadequate **p＜.01; ***p＜.001.
Low depressive
High depressive
Symptoms group
Symptoms group
(0-18)
(19-54)
n 835
(%) 72.3
n 320
(%) 27.7
227 461 147
27.2 55.2 17.6
79 171 70
24.7 53.4 21.9
74 270 491
8.9 32.3 58.8
51 106 163
15.9 33.1 50.9
66 304 465
7.9 36.4 55.7
43 121 156
13.4 37.8 48.8
105 730
12.6 87.4
65 255
20.3 79.7
142 693
17.0 83.0
72 248
22.5 77.5
62 257 516
7.4 30.8 61.8
40 133 147
12.5 41.6 45.9
96 739
11.5 88.8
87 233
27.2 72.8
40 795
4.8 95.2
28 292
8.8 91.3
323 512
38.7 61.3
254 66
79.4 20.6
101 734
12.1 87.9
103 217
32.2 67.8
112 723
13.4 86.6
115 205
35.9 64.1
201 634
24.1 75.9
171 149
53.4 46.6
469 366
56.2 43.8
246 74
76.9 23.1
109 726
13.1 86.9
144 176
45.0 55.0
657 178
78.7 21.3
154 166
48.1 51.9
χ2
p-value
2.92
0.232
13.30
0.001**
9.70
0.008**
11.03
0.001**
4.63
0.031**
24.85
＜0.001***
42.71
＜0.001***
6.55
0.011**
153.23
＜0.001***
64.22
＜0.001***
74.33
＜0.001***
91.37
