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 on depression in Malaysia, particularly validation studies and psychotherapy research, was weak and fragmented, with minimal empirical 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 efficacy of CBT. Major limitations of studies were noted, and, consequently, the problems that are associated with the implementation and future direction of clinical and research on depression in Malaysia were discussed. In short, the contribution of empirical research on the assessment and treatment for depression remained inconsistent and fragmented and urgently in need of further empirical investigation.
It is projected that depression, an affective disturbance, will be among the leading causes of worldwide disability, by the year 2020 [
Theories of psychological disorders (particularly depression) are both clear and abundantly found in the literature. These theories can be broadly classified into either biological or psychosocial. Pharmacological theories of depression, such as amine dysregulations, are well established [
It is also generally accepted in the literature that Cognitive Behaviour Therapy (CBT) is an effective way of treating depression [
In Malaysia, biological theories, and, thus, the pharmacological treatment of depression, are commonly used in clinical practices in community settings and hospitals; in fact, this is the main form of treatment for depression in Malaysia [
Since psychological theories and, thus, treatment are more susceptible to cultural influences, it is therefore important to establish the validity of Western-derived psychological theories and psychological instruments for use in the treatment of depression in different cultures, such as Malaysia [
A search of the literature using electronic databases for PsycINFO and Medline (1970–present) was conducted (see Figure
Flowchart of searching articles to review.
The search was refined to identify studies published in English over the last 30 years that included at least a cross-sectional and experimental study of depression using adult participants. Adult studies were targeted, in order to eliminate developmental differences in child or adolescent groups. Meta-analysis cannot be done due to the limited number of samples, variability of instruments used to measure depression, and insufficient reports on the statistical parts that are required for a systematic review. The publication years were chosen to incorporate the majority of studies, since the treatment for depression has been designed and researched.
Searches were conducted using the keywords, assessment, treatment, and Malaysia; and the following words in the title: depression, depressive disorder, and mood disorder. These keywords and title words were selected based on those found in the majority of papers collected earlier during the review process. Treatment keywords were combined to yield 425 citations in PsycINFO and 325 citations in Medline. The assessment terms were combined to produce 26 citations in PsycINFO and 28 citations in Medline. Studies were excluded for the following reasons: biological/physiological studies rather than treatment/assessment studies, depression was not the target of treatment, stress was misinterpreted as depression, and the article was a discussion of historical data rather than empirical studies.
This review process cannot exclude papers with no information on effect size, as that would lead to a limited number of papers to review. This process resulted in 12 studies that were suitable for the review. An additional six studies taken from local journals, which met the selection criteria, were cited in these articles and added to the review, resulting in a total of 18 studies.
The assessment studies, arranged by their year of publication, are presented in Table
Studies on the assessment of depression in Malaysia.
Study | Target group | Ethnicity (%) | Gender | Measure | Cronbach’s ( | Validity | EFA/CFA | |
(1) Quek et al. [ | Urological | 237 | Malays Chinese (majority) Indian | NA | BDI | Internal Rel. (0.56–0.87); test-retest (0.56–0.87) | Discriminant; specificity and sensitivity | NA |
(2) Azah et al. [ | Primary care | 265 | Malays (100) | Male | PHQ-9, HDRS, HADS | Internal Rel. (0.67); test-retest (0.73) | Concurrent; specificity and sensitivity | NA |
(3) Oei and Mukhtar [ | Students, general community, primary care, and depressed patients | 1050 | Malays (100) | Male | ATQ, BDI, DAS | Internal Rel. (0.90) | Concurrent and discriminant; specificity and sensitivity | EFA/CFA |
(4) Mukhtar and Oei [ | Students, general community, primary care, and depressed patients | 1050 | Malays (100) | Male | BDI, ATQ, DAS | Internal Rel. (0.90) | Concurrent and discriminant; specificity and sensitivity | EFA/CFA |
(5) Ramli et al. | Patients with diabetes | 153 | Malays (12) Chinese (16) Indian (17) | Male (75) Female (78) | DASS-21 | Internal Rel. (0.74–0.79) | Construct | CFA |
(6) Mukhtar and Oei [ | Students, general community, primary care, and depressed patients | 1050 | Malays (100) | Male | DAS, BDI, ATQ | Internal Rel. (0.82) | Concurrent and discriminant; specificity and sensitivity | EFA/CFA |
(7) Ramli et al. | Patients at Infertility Centre | 246 | Malays (230) Chinese (7) Indian (6) Others (3) | Male (123) Female (123) | DASS-21, HADS | Internal 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 Depression Scale; (PHQ-9): Malay Version of Brief Patient Health Questionnaire;
Meanwhile, for treatment studies, Table
Studies on the treatment of depression in Malaysia.
Study | Disorder or problem | Ethnicity | Gender | Design | Intervention | Duration of treatment | Outcome measure | Treatment result (+ve/−ve) |
(8) Woon and Teoh [ | Depression with hysterical personality disorder | Chinese | Female | Case study | Psychodynamic therapy and amitriptyline | 1 year and 5 months | NA | Positive |
(9) Ong and Lee [ | Depressive neurosis and manic depressive | Malay | Male | RCT | Nomifensine and amitriptyline | 9 weeks | HDRS; Global clinical parameter | Positive with few adverse effects |
(10) Indran [ | Depression (12) Dysthymia (3) Anxiety (3) Bipolar (1) Schizophrenia (1) (Outpatient) | Malays | Male | RCT | Moclobemide | 6 weeks | HDRS; CGI; PGI | Positive with few adverse effects |
(11) Azhar and Varma [ | Depression | Malays | NA | RCT | Religious | 15–20 sessions | HDRS | Positive |
(12) Razali [ | Depression | Malay | Male | Case study | Dothiepin and maprotiline | 3 month and 1 month | NA | Positive |
(13) Razali et al. [ | Depression | Malays | NA | RCT | Religious | 26 weeks | HARS; HDRS | Positive |
(14) Razali and Hasanah [ | Depression (Outpatient) | Malay | NA | RCT | Amitriptyline, imipramine, dothiepin and maprotiline | 8 weeks | HDRS | Positive |
(15) Razali [ | Masked Depression (Outpatient) | Malay | Female | Case Study | Dothiepin | 6 weeks | NA | Positive |
(16) Ng and Stevens [ | Depression | Malaysian Chinese | Male | RCT | Sertraline (SSRI) | 6 weeks | HDRS; CGI; LUNSERS; Plasma measurement | Positive with few adverse effects |
(17) Azhar et al. | Depression (Outpatient) | NA | RCT | CBT + ESCCBT + STRCBT + FXT | 12 weeks | HADS; BDI; WHO-QOL | Positive; CBT + ESC show better | |
(18) Mukhtar et al. [ | Depression (Outpatient) | Malays | Male | RCT | GCBT + TAUTAU | 8 sessions; 1 month | ATQ; DAS | Positive and maintained at 3 and 6 month followups |
Note: KEY to intervention (alphabetical order): Group Cognitive Behaviour Therapy (GCBT); Selective Serotonin Reuptake Inhibitor (SSRI); Escitalopram (ESC); Sertraline (STR); Fluoxetine (FXT); Treatment-as-Usual (TAU)Note: KEY to measures (alphabetical order): Automatic Thoughts Questionnaire (ATQ); Beck Depression Inventory (BDI); Clinical Global Impression (CGI); Dysfunctional Attitude Scale (DAS); Hamilton Anxiety Rating Scale (HARS); Hamilton Depression Rating Scale (HDRS); Liverpool University Neuroleptic Side-effect Rating Scale (LUNSERS); Patients Global Improvement (PGI).
A total of 18 studies fulfilled the above criteria for inclusion. Of these, seven studies were psychometric validation of a depression instrument and 11 studies were for treatment outcome of depression (Table
In a review on assessments used to measure depression, three aspects will be discussed: subjects, measures used, and the statistical method. Table
In terms of measure, four studies (Studies 1, 3, 4, and 6) [
Meanwhile, in terms of statistical analyses, both internal reliability and validity analyses were mentioned in all studies. Specifically, BDI studies have reported Cronbach’s alpha between 0.56 to 0.90 and test-retest realibility (0.56–0.87). Meanwhile, for DASS-21, Cronbach’s alpha and test-retest reliability are between 0.74–0.83 and 0.82–0.84, respectively. In addition, for the PHQ-9, HDRS and HADS, their Cronbach’s alpha is 0.67 and test-retest reliability is 0.73. Meanwhile, Cronbach’s
To sum up this section, the above showed that two instruments for assessment of symptoms of depression had good valid and reliable psychometric information and thus can be used with some confidence for clinical research. Others such as PHQ-9, HDRS, and HADS have minimal psychometric validation information and thus must be used with caution.
A review on treatment of depression that has been reported in Malaysia includes two general approaches (a) pharmacotherapy 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 intervention between 6 weeks and 17 months, but recent studies reported similar significant outcome completed the intervention in 4 weeks for 8 sessions of Group CBT approach. The majority of treatment studies (see Table
In terms of subjects that have undergone treatment research of depression in Malaysia, both Malays and female are the dominant ethnic and gender that have been mostly researched. Only Studies 9, 10, and 16 were combining all three ethnic groups in Malaysia, otherwise other studies reported subjects and were only among Malays.
Table
Among all studies on pharmacotherapy, four studies (Studies 9, 10, 14, and 16) [
Besides RCT studies, interesting findings were from two case studies using two (Study 12) and one (Study 15) Malay patients with major depression who attributed their presenting symptoms to witchcraft or possession by evil spirits [
Although Razali and Hasanah [
Besides pharmacological treatment, patients also have the alternative choice of psychotherapy treatments to treat symptoms of depression; several studies [
In this paper, four types of psychotherapies have been reported such as psychodynamic (Study 8) [
RCT study has been applied in four studies (Studies 11, 13, 17, and 18) for Malay patients with depression, except Study 18 which included patient with anxiety in their intervention. There are two RCT studies using religious psychotherapy, one is comparing to supportive psychotherapy and the other study was comparing to supportive psychotherapy and benzodiazepine. Meanwhile, for Cognitive Behaviour Therapy, Study 17 was comparing three groups of CBT with combination of Escitalopram, Sertraline, and Fluoxetine, respectively. The only Group CBT plus Treatment-As-Usual (TAU) study was conducted recently by comparing with Treatment-As-Usual group.
From all these studies, the recent study on Group CBT reported the shortest duration of treatment which is four weeks with eight sessions, and the outcome response is as successful as longer session. Otherwise, other psychotherapy studies in this review reported duration of treatment from 12 weeks to 26 weeks. However, Study 11 did not report on duration of sessions, but only reported that 15–20 sessions were completed by the participants.
This section also concluded that there is only one randomised control study on GCBT since its introduction in the early 1990s. Group intervention has been introduced in Malaysia in religious psychotherapy; thus, the GCBT study supports the notion that this form of treatment may be applicable to Malaysia, in particular the Malays as long as therapists are sensitive to the religious-sociocultural issues to which the group belongs. Hence, they concluded that the cognitive-behavioural approach complements and is compatible with the influence of religious values and has been especially effective in treating depressed patients [
Beside cognitive behaviour therapy, the efficacy of psychodynamic approach (Study 8) [
In terms of outcome measure, all RCT studies reported using Hamilton Depression Rating Scale, while Study 17 used Beck Depression Inventory and Hospital Anxiety and Depression Scale. Meanwhile, the GCBT study (Study 18), instead of using symptom outcome measure, reported using cognitive measures to assess the effectiveness of the treatment. Most of the studies did not report on follow-up sessions, clinical and statistical significance, and effect size except Study 18.
This present paper aimed to review all studies performed in Malaysia, which were divided into two themes, namely, assessment and treatment of depression. It becomes clear that research on depression in Malaysia has a long way to go before psychiatric services are able to provide an ideal level of service for the community.
Research studies vary in methodology and design and, thus, often present with conflicting findings in all areas including assessment and treatment. Consequently, small sample sizes, inadequate information on subjects’ recruitment and randomisation of the sample, unclear diagnosis and treatment protocol procedure, lack of validated instruments, limited outcome measures or variables, problems with homogeneity of samples, and problems with generalisation of the results occur. In addition, for the treatment studies, information on effect sizes and also clinical significant change were seldom given.
For the psychometric assessment, it was unfortunate that only one study used exploratory and confirmatory factor analysis in order to validate the instruments used in Malaysia. Thus, weak statistical methodology used in validation studies overstated the reliability and validity of the instruments reviewed. While the BDI had been shown to have good psychometric properties, yet only Study 4 gave a precise numbers that used the BDI as a symptom measure for depression. It was noted in Tables
In summary, there is evidence that some progress had been made in improving the assessment and treatment for patients with depression. Recently, an indigenously constructed and validated instrument for the screening of mental health problem was developed [
The authors would like to express their warmth gratitude to Professor Sherina Mohd Sidik and Associate Professor Ramli Musa for their kindness to share their publication in order to make this paper possible. This paper is part of doctorate thesis for the first author and had received no funding sources and no conflict of interests.