S. Naeem  ( Department of Psychiatry The aga Khan University, Karachi. )
B.S. Ali  ( Department of Family Medicine The aga Khan University, Karachi. )
A. Iqbal  ( Department of Community Health Sciences**, The aga Khan University, Karachi. )
S. Mubeen  ( Department of Community Health Sciences**, The aga Khan University, Karachi. )
A. Gul  ( Department of Community Health Sciences**, The aga Khan University, Karachi. )

The life time risk of an individual developing a depressive episode now approaches 15%. 1 The World Health Organisation ranks depression as the world\'s fourth greatest public health problem 2 with an expected certain increase in the burden in future. 3 Women are said to have a 1.7 times life time risk of developing a major episode in United States 1 ; a greater than twice male to female ratio has been reported in Pakistan. 4,5 Many ailments are self-limiting and improve with time irrespective of treatment 6 and this change is called spontaneous remission or in statistical terms regression to the mean. Rearchers have tried to explore the factors that influence this phenomenon. For anxiety and depression severity of the initial episode, duration of depression 2 and a passive dependent personality trait 7 are reported as barriers to spontaneous recovery. Goldberg et al studied certain social and personality factors that help a person in recovering from anxiety and depression and termed these \'factors for restitution\'. 8 The extent of influence of adverse life events/stressors on remission is still open to debate 7 though it is reported that, there is a difference in recovery between those who suffer from adverse life events/stressors and those who do not inspite of adequate treatment. 9 Community based studies in various regions of Pakistan have reported figures for depression in women varying from 66% in rural Punjab5 to 30% in semi-urban Karachi.l0 The health services in Pakistan are ill equipped in terms of resources to deal with this burden, and factors of vulnerability and restitution need to be explored in order to prevent/minimize morbidity from anxiety and/or depression. This paper analyzes these factors in a group of women who made a spontaneous remission/recovery from anxiety and/or depression.

This is a nested study from a randomized controlled trial to see the effects of brief counseling by minimally trained community counselors on levels of anxiety and/or depression in women of their own community.11 In this RCT the an indigenously developed and validated instrument "Aga Khan University Anxiety and Depression Scale (AKUADS)"12.13 was used to identify anxious and/or depressed women in a semi-urban community of Karachi, who were then randomized to intervention or control groups. A survey carried out after 8 weeks of counseling of the intervention group showed that out of the 150 women in the control group, spontaneous improvement had occurred in 19 and 10 of them were no longer anxious and/or depressed according to AKUADS scores. These 10 women were invited for Focus Group Discussion (FGD) but only 7 consented. All of them were married, were between 22- 40 years and had 1-8 children. Only 4 could read and write. The FGD was conducted at a local hospital in the community. A guideline was prepared to explore the perceptions of causes for poor mental health in the group (vulnerability factors) and the strengths, resources and coping strategies that had helped their recovery (restitution factors). Guidelines for Focus Group Discussion (FGD) Introduction and explanation of the process. - What is mental health? - How do you recognize poor mental health? - What are the factors for poor mental health? - What do you do to cope with such problems? - What has helped in the past? Did any significant event occur in the past few months? - Any suggestions or recommendations for improving the mental health of your community?

Perceptions of causes of poor mental health (vulnerability factors) The group regarded unemployment and poverty as the main causal factors for poor mental health. Most of them felt that worries related to day to day problems would keep adding up and every additional need, e.g., a marriage or an illness in the family could trigger a state of \'tension\' or \'depression\'. Some of the ongoing difficulties that were thought to be compounding the financial problems were: \'not having enough earning members in the family\', \'living in a rented accommodation\' or the realization that \'there were many daughters that needed to be married off,’ Strengths, resources and coping strategies (restitution factors) What was noticeable in this group was the absence of severe relationship problems or domestic abuse, only one woman reported occasional abuse. Sharing worries/problems with immediate family members, other relatives, friends or neighbors was often used as a coping strategy. "...if we go to someone else and share our problems, it reduces our tension. If we stay quiet the tension builds up". Each participant had someone whom they could turn to when in distress. This reflected a fairly reliable support system. Crying was another source of reducing \'tension\' for this group. "... a little bit of crying makes the heart feel lighter". The participants also emphasized keeping a positive approach towards life helped them to over come \'tension\'. "... when we look at other people who have more problems than us, then our own problems (worries) seem minor." Faith in Allah (God) also helped them ward off anxiety / depression. "... offering namaz (prayers) five times a day and the thought that Allah is with us keeps distressing thoughts away" Positive events When asked about any recent positive event in their lives, that might have occurred during this period two women reported: "... I had a son after 11 years of my marriage". " ...I have forgotten all about my sorrows because of my daughter\'s success in the matriculation exams". But interestingly, when asked if they had perceived any positive changes in themselves over the past two months, they were not aware of any significant change.

Abuse has been reported as a risk factor for depression in other studies 11 and this study lends credence to it. A dependable social support system was reported by the participants as a restitution factor which is also similar to other studies, Esquiage et al14 had found an association between depression and low satisfaction with their social support in women. Kuboki 15 mentioned psychosocial support as one of the important factor resulting in improvement of mild depression. Women in this study reported using crying as a method of catharsis. Peden 7 in a qualitative study on recovery from depression cited cognitive strategies as being crucial and interestingly the participants of our study new that positive thinking can have a positive effect on their mood. Muelle et al 17 have observed an association of religious involvement and spirituality with lower levels of anxiety, depression and suicide. Also Baetz et al 18 in their recent study on Canadian psychiatric in-patients observed less severe depressive symptoms among frequent church attendees, having faith and praying have been mentioned as ways for reducing tension by the women involved in our FGDs. Turning point experiences have been mentioned by Peden as playing an important role in recovery from depression. 19 Brown et al 20 termed such positive events as \'fresh start events\' that help recovery. Two out of seven in our group reported such an event during the 8 week study period. This study confirms that the vulnerabilities, strengths and resources identified in studies conducted in other countries are similar to those identified by our study population. The similarity suggests that the results could probably be cautiously generalized to other areas of Pakistan, though the authors remain conscious that the small numbers and just one semi-urban setting are limitations.

We wish to thank all the people of Qayoomabad, and the administration of Sir Syed Hospital Qayoomabad 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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Objective: To gain insight into the perceived vulnerability and restitution factors for anxiety/or depression.
Methods: Focus group discussion of seven married women recovered spontaneously from anxiety and/or depression, belonging to a lower middle class semi-urban community of Karachi.
Results: Poverty, unemployment, abuse and on going difficulties were perceived as risk factors for depression, A reliable social support system, positive thinking approach, faith, prayers, and experiencing a "turning point" event were reported as factors that promoted recovery from anxiety and/or depression.
Conclusion: Individual vulnerabilities, strengths and resources can have an important role in recovery from anxiety and/or depression in women (JPMA 54:49;2004).