Mood Symptoms, Suicide, and Associated Factors Among Jimma Community. A Cross-Sectional Study

Background: The global burden of mental health problems is high and is predicted to rise. At present, mood symptoms are the foremost common psychological problems worldwide, yet little is known regarding their magnitude and associated factors in developing countries. Therefore, this study aimed to assess the magnitude and associated factors of anxiety, depressive, manic symptoms, and suicidal behavior among the rural Jimma community, Ethiopia. Methods: A community-based quantitative cross-sectional survey was employed on 423 households selected through systematic random sampling. An adapted version of the Mini International Neuropsychiatric Interview tool was used for the structured face-to-face interview. The collected data were checked for completeness, coded, and inserted into Epi Data version 3.1 and exported to SPSS version 23 for analysis. Variables with P < g0.05 and odds ratio (OR) [95% confidence interval (CI)] on multivariate logistic regression analysis were considered as factors associated with the outcome variable. Results: Overall, 185 (44.0%), 55 (13.1%), 44 (10.5%), and 23 (5.5%) of the respondents had anxiety, depressive, manic symptom, and suicide behavior, respectively. The odds of having anxiety symptoms were nearly 5 times higher among those who had perceived discrimination and racism experience compared to their counterpart [adjusted OR (AOR), 5.02; 95% CI, 1.90–13.26]. Likewise, recently bereaved participants had 4-fold higher odds of reporting depressive symptoms (AOR, 3.9; 95% CI, 1.4–10.4) than the non-bereaved ones. Furthermore, respondents who had depressive symptoms were almost four and a half times more likely to have manic symptoms compared to those who did not (AOR, 4.3; 95% CI, 1.71–11.02). Conclusion: Anxiety, depressive, manic symptoms, and suicidal behavior were prevalent in the community and positively associated with multiple psychosocial factors. Implementing accessible and affordable community-based mental health services is recommended to mitigate the problems.

events, poverty, and other demographic disadvantages pose a greater risk for mental health problems (32,33). Also, various sociocultural factors such as deeply ingrained religious and inherited beliefs that all mental illnesses contribute to the existence and poor modern treatment for mental health problems in the country (34). In Ethiopia, in any ethnic or religious group, supernatural powers are given the attribute of controlling the well-being of the individual's mind. The traditional healing methods are used more by most people (35)(36)(37).
In Ethiopia, where undernutrition and preventable communicable diseases are very rampant, mental health problems, which are considered as non-fatal, are not given due consideration (38). Valid and inclusive epidemiological data on the magnitude and associated factor of mental health problems generated from community-based surveys have significant scientific and health policy implications (39). There are some research works documented in the literature regarding the magnitude and associated factors of anxiety, depressive, manic symptoms, and suicidal behavior among Ethiopians. However, in this study, variables such as migration history, perceived discrimination and racism experience, sexual abuse, and domestic violence were included. Furthermore, the studies on mental health problems are scarce in the sub-Saharan countries, and most studies were conducted in the cities. However, this study has tried to reveal the extent of mental health problems and associated factors in the neglected rural area of the country; this might help the local health planners and non-governmental organizations working in the area of mental health to investigate and design effective locally sound mental health interventions to avert the problems. Hence, this study aimed to assess the magnitude and associated factors of anxiety, depressive, manic symptoms, and suicidal behavior among the Jimma zone community, Ethiopia.

Study Setting
The study was carried in the Jimma zone, Seka Chekorsa district. Jimma zone is administratively divided into 20 districts and one town administration. The total population of the zone was 2,986,957 in 2017 (40). Seka Chekorsa district is located 20 km from Jimma town, and the district has 30 kebeles (the lowest administrative division in the area) with a total population of 208,096 (41). This district has one primary hospital, nine health centers, and 35 health posts. The study was conducted from March 1 to 22, 2020. Ethiopia is one of the 213 countries that have registered 2019 coronavirus disease (COVID-19) cases since March 13, 2020. In Ethiopia, several cases and deaths are identified (42). The study data were collected in the first couple of weeks of the virus detection in the country.

Sample Size Estimation
Single population proportion formula was used to obtain the desired sample size. We have assumed a 50% proportion of the magnitude of mood symptoms to get the maximum sample size, 95% confidence level, and 5% margin of error. Hence, n = (zα/2)² P(1-p)/d²; hence, n = (1.96) 2 × 0.5 (1-0.5)/(0.05) 2 = 384. With the addition of a 10% contingency for non-response, the final sample size was 423.

Study Design, Population, Sampling Technique, and Procedures
A community-based quantitative cross-sectional survey was carried out. First, Seka Chekorsa district was selected from a total of 20 districts in the zone through a simple random sampling lottery technique. Of the 30 kebeles in this district, nine were selected by lottery method based on the WHO sample size calculation guideline for the district health system (43). The number of sampled respondents from each kebele was determined by proportional allocation to the total number of households in each of the sampled kebeles. A systematic random sampling technique was used to select the study units, and periodic interval (K) was calculated using the formula K = N/n, whereby N is the total households in the selected kebeles (1,555), and n is the calculated sample size (423). Accordingly, every four households were included in the study. The first study unit was selected by lottery method between the first and fourth households. Finally, randomly selected household members 18 years or older in the selected household responded to the interview. The study participants were household members 18 years or older in the randomly selected households.

Eligibility Criteria
All the study community members 18 years or older were included in the study. The study community members who were acutely or chronically ill, which makes him/her difficult to participate in the study, were excluded from the study.

Measurements and Procedures
A face-to-face interviewer-administered structured questionnaire was used using an adapted version of the Mini International Neuropsychiatric Interview (M.I.N.I.). M.I.N.I. 5.0.0 was developed by Sheehan et al. and designed for assessing the major Axis I mental health problems in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (researchers and clinicians working in non-profit or publicly owned settings can freely use for clinical and research use) (44). Validation and reliability of the tool have been done with good psychometric properties (45)(46)(47). The reliability, Cronbach α score, of the scales in this study was 0.76. This study has assessed the prevalence of DSM-IV criteria A symptoms of panic disorder (lifetime), social anxiety disorder (past month), generalized anxiety disorder (past 6 months), suicide characteristics (such as repeatedly consider hurting self, having a plan to kill self, repeatedly wish dead, and suicide attempt) (past month), a lifetime suicide attempt, major depression (current or 2 weeks), and manic episode (lifetime). The tool has also included questions to measure other family members with such symptom presentations. If the subject answers positive for any of the questions about symptoms included in M.I.N.I.'s anxiety, depressive, manic symptoms, and suicide module, it is considered to have the symptoms. For factors associated with the outcome variable, the questionnaire was developed after a thorough review of the literature that has been done on similar topics (32,(48)(49)(50); the presence or absence of these factors was measured using a structured question. Data were collected by 20 health extension workers after receiving training for 2 days on the components of the questionnaire, data recording, and the ethical principles of the data collection process. The English version of the questionnaire was translated into Afaan Oromo and back-translated to English to ensure its uniformity by blinded language experts. The translations were face validated by two independent external experts in the field. Moreover, the data collection tool was pilot tested on 5% of the population in another district to ensure its clarity and consistency. The pretest results showed the questionnaire was easily understandable, and the interview process was clear for the respondents. Afaan Oromo version of the questionnaire was used to obtain the desired data. Appropriate COVID-19 infection containment measures, which WHO recommended (keeping a 2-meter distance, wearing a face mask, and using alcohol-based hand sanitizers), were practiced during the data collection period.

Data Organization and Statistical Analysis
The collected data were checked for completeness, given code, and inserted into Epi Data version 3.1 and exported to SPSS version 23 for analysis. Descriptive statistics were done to summarize the variables. The logistic regression analysis model was used to identify the factor associated with the outcome variable. First, bivariate logistic regression analysis was done, and variables with p < 0.25 were selected as candidate variables for multivariate logistic regression analysis. After the model was tested for multicollinearity and Hosmer-Lemeshow test of model fitness, the final multivariate logistic regression analysis was carried out. Finally, variables with p < 0.05 and 95% confidence interval and odds ratio (OR) were considered as factors associated with the outcome variable.

Ethical Consideration
Ethical approval was obtained from the Institutional Review Board (IRB) of Jimma University (IHRPGD/584/2019). Additionally, a support letter was found from Oromia Regional Health Bureau, Jimma Zone Health Bureau, and a subsequent support letter was obtained from the Seka Chekorsa district health office before the commencement of data collection. Respondents were informed of the study objectives and were assured of the anonymity of their participation. Participation in the study was voluntary, and written informed consent was taken from the respondents. Respondents who had anxiety, depressive and manic symptoms, and suicidal behavior were advised to visit the nearby health facility for further mental health evaluation and management.

Sociodemographic Characteristics
A total of 420 study participants were interviewed successfully, giving a response rate of 99.3%. Three respondents were not willing to participate in the study. The mean age of the respondents was 37.2 years (SD, ±11.9 years) with a range of 18

Anxiety Symptoms
Twenty-eight participants (6.7%) had spells or attacks of sudden anxiety, frightened, uncomfortable, or uneasy, even in situations where most people would not feel that way on more than one occasion. Similarly, about 71 (16.9%) respondents were fearful or embarrassed by being watched including things such as speaking in public, eating in public or with others, writing while someone watches, or being in social situations in the past month. Nearly one-quarter [101 (24.0%)] of the participants were worried excessively or had been anxious about several things over the past 6 months. Overall, 185 (44.0%) seemed to have anxiety symptoms ( Table 2).

Depressive Symptoms and Suicide Characteristics
Of the total respondents, 39 (9.3%) reported they have been consistently depressed, hopeless most of the day, nearly every day, for the past 2 weeks or more. About 31 (7.4%) participants could identify another family member who was tearful, hopeless, and complaining about emptiness for the past 2 weeks or more. About 40 (9.5%) of the respondents were less interested in most things or much less able to enjoy the things they were used to enjoy most of the time in the past 2 weeks or more. Additionally, 23 (5.5%) of the participants reported repeatedly wishing to be dead, and 5 (1.2%) attempted suicide. Overall, 55 (13.1%) of the respondents had depressive symptoms ( Table 3).

Manic Symptoms
Among the total respondents, 11 (2.6%) had a lifetime period where they feel "up" or "high" or "hyper" or so full of energy or full of self that got into trouble, or other people thought they were not their usual self for 1 week or more. About 38 (9.0%) of the participants described persistently feeling irritable, had arguments or verbal or physical fights, or shouted at people for several days. Overall, 44 (10.5%) of the respondents were identified to have manic symptoms ( Table 4).

Respondents' Psychological and Behavioral Characteristics
Among the respondents, 48 (11.4%) had a recent loss of a close family member. About 45 (10.7%) participants were reported being discriminated against. About 12 (2.9%) had confided about being sexually abused, and 118 (28.1%) described financial problems ( Table 5).

Factors Associated With Anxiety Symptoms
Male participants had a 50% less risk of developing anxiety symptoms [adjusted OR (AOR), 0.50; 95% CI, 0.29-0.87]. The analysis results also showed rural residents were found to have a 75% less risk of having anxiety (AOR, 0.25; 95% CI, 0.14-0.44).
The odds of having anxiety symptoms were ∼2 times higher among those who were on the first birth order than those on the third or more birth order. Those employed had 57% less risk of developing anxiety symptoms compared to the housewife counterpart (AOR, 0.43; 95% CI, 0.20-0.90). Respondents whose parents abuse substances had nearly twice increased odds of developing anxiety symptoms (AOR, 2.18; 95% CI, 1.12-4.22). The odds of developing anxiety symptoms were ∼5 times higher among those who had perceived discrimination and racism experience (AOR, 5.02; 95% CI, 1.90-13.26). Respondents who had reported stressful event had nearly 4 times' increase of having anxiety symptoms (AOR, 3.96; 95% CI, 1.53-10.24) ( Table 6).

Factors Associated With Depressive Symptoms
The analysis result has shown depressive symptoms were three and a half times higher among respondents who were unable to read and write compared to primary school and above academic status (AOR, 3.5; 95% CI, 1.3-8.9). Respondents who were on the first birth order were nearly three and a half times more likely to have depressive symptoms compared to those on the third and above birth order (AOR, 3.6; 95% CI, 1.4-8.7). The study participants who had recent bereavement were nearly 4 times more likely to report depressive symptoms (AOR, 3.9; 95% CI, 1.4-10.4). Furthermore, respondents who had depressive symptoms were ∼5 times higher to have stressful events compared to their counterparts (AOR, 4.8; 95% CI, 1.7-13.5) ( Table 7).

Factors Associated With Manic Symptoms
Respondents who had depressive symptoms were almost four and a half times more likely to have manic symptoms (AOR, 4.3; 95% CI, 1.71-11.02). Study participants with parental substance use history were 3 times more at risk of having manic symptoms (AOR, 2.8; 95% CI, 1.21-6.69). The result of the regression analysis has revealed respondents who had perceived discrimination and racism experience had 5 times more likely to report manic symptoms (AOR, 5.0; 95% CI, 1. 96-12.77). Firstborn children had ∼4 times higher risk of developing manic symptoms compared to those on the third or more birth order (AOR, 4.1; 95% CI, 1.29-12.98). Study participants who perceived their economic status as a medium were two and a half times more likely to have manic symptoms than those who perceived low economic status (AOR, 2.3; 95% CI, 1.06-5.24) ( Table 8).

DISCUSSION
The study aimed to assess the magnitude and factors associated with anxiety, depressive, and manic symptoms, and suicidal behavior among the Jimma zone community.
The finding of this study showed 55 (13.1%) of the respondents had depressive symptoms. Consistent findings were reported from the pooled prevalence of depression in Ethiopia (51), rural communities in Malaysia (11.30%) (10), Brazil (14%) (52), northwest Ethiopia (17.5%) (53), and Puerto Rico (17.8%) (54). The findings in all studies have shown that depression is a   higher rates of pollution [e.g., air, water, and noise pollution in the cities might be the reason for the high prevalence of depression symptoms (57,58)]. Manic symptoms were noted in 44 (10.5%) of the respondents; similarly, the US National Epidemiologic Catchment Area database showed that the prevalence of subthreshold bipolar symptoms was 5.1% (59). At present, no data exist that indicate how many patients there are with such subthreshold bipolar symptoms in the developing countries and community setting. The high prevalence of substance (Khat) use, socioeconomic pressure, and limited availability of mental health treatment centers in the area might contribute to the symptoms (39,60).
The finding of this study has shown 185 (44.0%) of the respondents had anxiety symptoms. This finding is higher than those found in the studies done in Malaysia (8.2%) (15), from African cultures (7.3%) to Euro/Anglo cultures (10.4%) (61), rural communities of Northern India (22.7%) (62), and Kashmir valley (26%) (17). The worries and uncertainty resulting from living in poverty seem to be an important driver of mental health

Variable Characteristics Frequency Percentage
Had a period feeling "up" or "high" or "hyper" or so full of energy or full of self that got into trouble, or that other people thought you were not your usual self for at least 1 week problems including anxiety, as do the effects of low income on childhood development and one's living environment (63). In this study, 5.5 and 1.2% of the participants reported repeatedly wishing dead and attempting suicide, respectively. A consistent finding was reported from the study done in Addis Ababa, Ethiopia, in which the rates of suicidal ideation and attempt were 2.7 and 0.9%, respectively (64). Another population study in Ethiopia has shown 13.5% of the study participants had suicidal ideation, and 1.8% had suicide attempt (65). Additionally, a study was done in Nigeria that revealed 7.28% had suicidal ideation (66). A study done in rural communities in China reported 4.8% and 0.4% had suicidal ideation and attempt, respectively (67). However, our finding was lower than the findings of 17.1% for suicidal ideation and 2.8% for suicide attempts from Brazil (68). The discrepancy could be explained by the differences in the social control networks, extended family ties, religious, cultural practices differences, and different stressors in the study settings (7,69).
The finding of this study has revealed that respondents with higher educational status had less risk of developing depression. This is consistent with the studies done in Iran (18) and Pakistan (70). This could be because education as a means enables people to gain success in life and may fundamentally contribute to the emotional well-being of the person (71). In the study area, an individual with higher education status usually has better work opportunities, health information, and living standards.   This could protect them against developing depression (72). Nevertheless, individuals with higher education backgrounds were comparatively more prone to mood disorders in the study done in the United States (10). This might be explained in that in Western culture highly educated people seek well-paid jobs and may have better socioeconomic expectations. In their race to meet these expectations, they could experience unmanageable stress, which predisposes them to mood disorders (73).
In the current study, respondents with first and second birth order status were more prone to have depression symptoms than those with third and above birth order status. This finding is in line with the study done in Nepal (74). However, no difference was observed in the study done in Egypt (75). Similarly, birth order was found to have an association with anxiety symptoms in this study. This finding was consistent with the study done in Kuwait (69). Birth order is one of the most significant life factors, and it is the best indicator of the kind of personality someone has. In the study area, the oldest child commonly has many responsibilities compared to the youngest child of the family. Studies also have shown that because of much expectations that are placed on the oldest child in a family, the eldest one experiences more emotional disturbance and struggles in coping with the stressful condition (76). In addition, the firstborns were considered as the smaller version of their parents; therefore, they have received much more control and attention from their parents. Hence, they tend to be over responsible, reliable, well-behaved, and careful. This might explain a higher level of emotional disturbances in this group (77). In our study, respondents with self-perception of their economic status as a medium were at higher risk of having manic symptoms. In many studies, it was usually noted that bipolar disorder was relatively higher among those who have medium socioeconomic status than that of controls or the general population (78,79). However, many current studies have failed to confirm such assumptions (12). The anticipation of economic shocks may cause mental illness such as mania. People living in poverty face substantial uncertainty and income volatility and complex financial portfolios, often without access to formal insurance; this might increase the risk of developing bipolar symptoms (80,81).
In the current study, having depressive symptoms was associated with an increased risk of manic symptoms. This might be explained by bipolar disorders beginning with depressive episodes, and a significant proportion of individuals who had initial major depressive disorder will later be reclassified as having a bipolar disorder (82). Various precipitating factors, such as socioeconomic stress, poor control of depressive-manic symptoms through medication, and the nature of the illness by itself, might be the reason for manic-depressive cycle (83,84).
Perception of prejudice and discrimination based on ethnicity increased the risk of presentation of manic and anxiety symptoms among the respondents. Stress associated with the experiences of perceived racial discrimination and prejudice has substantial negative effects on both physical and mental health and might precipitate mental health problems (85). Discrimination may contribute to psychological problems through numerous possible mechanisms including negative psychological and physical stress response, hypervigilance, and increased involvement in unhealthy behaviors (20,86,87). In Ethiopia, ethnicity-related violence in different parts of the country could be the reason for the death, and internal displacement of people from their living area can be considered as a serious stressor for manic symptoms eruption (88,89).
In this study, respondents whose parents abuse substances were more likely to have anxiety symptoms. This could be because an individual who had parents with abusing substances were having problems including poor attachments, economic difficulties, legal problems, emotional abuses, and violence (90).
However, this article has presented psychiatric symptoms, not disorders. Additionally, some of the discussion comparisons were made with many countries that are culturally different from this study setting. So, the generalization and conclusions should be made cautiously. Moreover, as it is cross-sectional by nature, it does not show the cause-and-effect relationship between the outcome and explanatory variables. Ethiopia has registered the first COVID-19 cases on March 13, 2020, the period where this study was conducted. Even though the study was conducted in a rural part of Ethiopia, where the spread of the infection was gradual, this might affect the results of this study. The current study did not assess some of the anxiety symptoms in agoraphobia, posttraumatic stress disorder, and obsessivecompulsive disorder. Furthermore, the study tool to assess the variables of this study was not validated in the local, Afan Oromo, and Amharic languages. Additionally, the latest version of the M.I.N.I. questionnaire was not used because the study tool was restricted by the publisher for free use.

Future Directions
Based on this study's limitations, we recommend interested researchers in the field of mental health and public health to investigate further the magnitude of psychiatric disorders with the latest and validated tools in local languages with a larger sample size. Furthermore, longitudinal studies are recommended to explore the cause-and-effect association of the outcome and explanatory variables.

Clinical Implications of the Study
This study may have an immense contribution in improving the mental health service of the study area by revealing the magnitude of the problems and contributing factors. In the study setting, there were very limited mental health services, which do not match with the rates of mental health problems as found in this study. This study will further motivate the researchers to evaluate the study population's intention to use mental health services, and the presence of stigma on patients with mental health problems and services use that require effective locally sound education programs in the study setting.

CONCLUSIONS
The study has revealed that a significant proportion of the community members have anxiety depressive, manic symptoms, and suicidal behavior. Furthermore, various risk factors were identified to have an association with the problems. Therefore, appropriate community-based mental health services should be designed and implemented to address the negative impact of the problems.

DATA AVAILABILITY STATEMENT
The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.

ETHICS STATEMENT
The studies involving human participants were reviewed and approved by the institutional review board of Jimma University, Institute of health. The patients/participants provided their written informed consent to participate in this study.

AUTHOR CONTRIBUTIONS
YT was the principal investigator of the study and was involved from inception to design acquisition of data, analysis, and interpretation, and drafting and editing of the manuscript. LA, SA, GT, ZB, GA, MG, and KY were involved in the reviewing of the proposal, tool evaluation, interpretation, and critical review of the draft manuscript. All authors read and approved the final manuscript.

FUNDING
Jimma University has funded the study. The funders had no role in the design of the study data collection, analysis, interpretation, and writing of the manuscript.