Prevalence and determinants of post-traumatic stress disorder five months after the 2019 huge flooding in Iran.

BACKGROUND: Despite the high occurrence of floods in Iran, its psychological consequences have been less discussed. The present paper addresses the prevalence of Post-traumatic Stress Disorder (PTSD) and its determinants among the affected adults by the huge flood of 2019. METHODS: An analytical cross-sectional study was conducted through household face-to-face surveys in August and September 2019. Individuals who were affected by floods and were at least 16 years old were randomly selected from three provinces in Iran: Lorestan and Khuzestan in the west and southwest, and Golestan in the northeast. The questionnaire of demographic and flood related variables in addition to the Impact of Event Scale-Revised (IES-R) were utilized to collect the data. We applied a complex sample analysis to describe the prevalence of PTSD and logistic regression analyses to find its determinants. RESULTS: Out of the 2,305 individuals approached for surveys, 1,671 (72.5%) adults affected by the floods participated in the study. The majority of participants were housewives, married, had either no formal education or primary education, and resided in rural areas. The prevalence of PTSD in the participants was 24.8% (CI 95%: 20.7-28.8%) and was significantly higher in Lorestan province (39.7%, P < 0.001). Determinants of PTSD, were unemployment (adjusted odds ratio [AOR] = 3.53, CI 95%: 1.38-9.00), primary (AOR = 2.44, CI 95%: 1.10-5.41) or high school (AOR = 2.35, CI 95%: 1.25-4.40) education (vs. university), a history of mental disorders (AOR = 2.36, CI 95%: 1.22-4.58), high damage to assets (AOR = 2.29, CI 95%: 1.40-3.75), limited access to health care services after the flood (AOR = 1.95, CI 95%: 1.20-3.19), not receiving compensation for flood damage (AOR = 1.94, CI 95%: 1.01-3.83), high wealth index (AOR = 1.90, CI 95%: 1.23-2.93), and flooded house with a height of more than one meter (AOR = 1.66, CI 95%: 1.02-2.76). CONCLUSION: Results show a notable prevalence of PTSD, especially in Lorestan province, among adults affected by floods. Determinants of PTSD include unemployment, lower education, psychiatric history, extensive property damage, limited post-flood healthcare access, lack of compensation, and increased flood exposure. We recommend adopting an inclusive screening approach for high-risk groups and developing appropriate therapeutic and supportive interventions.

Psychological impact of the Spring 2019 flood among adult population of Iran.

BACKGROUND: From March to April 2019, a flood occurred in several regions of Iran. The most affected provinces were Golestan, Lorestan, and Khuzestan. AIMS: The present study aimed to determine the prevalence and determinants of psychological distress and depression among the affected adult population 6 months after the event. METHODS: A cross-sectional household survey with face-to-face interview was carried out on a random sample of 1,671 adults aged above 15 years living in the flood-affected areas from August to September 2019. We applied GHQ-28 and PHQ-9 for the assessment of psychological distress and depression, respectively. RESULTS: The prevalence of psychological distress and depression were 33.6% (95% CI [29.5, 37.7]) and 23.0% (95% CI [19.4, 26.7]), respectively. Determinants of psychological distress were a history of mental disorders (Adjusted odds ratio [AOR] = 4.7), primary (AOR = 2.9) or high school (AOR = 2.4) education (vs. university), no compensation received (AOR = 2.1), high damage to assets (AOR = 1.8), the house flooded more than 1 m (AOR = 1.8), female gender (AOR = 1.8), and limited access to health care services (AOR = 1.8). Determinants of depression were unemployment (AOR = 5.3) or being a housewife (AOR = 2.7), a history of mental disorders (AOR = 4.1), high damage to assets (AOR = 2.5), no compensation received (AOR = 2.0), the house flooded more than 1 m (AOR = 1.8), limited access to health care services (AOR = 1.8), and high wealth index (AOR = 1.7). CONCLUSION: The results of this study revealed a high prevalence of psychological distress and depression in the flood-affected adult population. The high-risk group, particularly flood victims who had a history of mental disorders, and those exposed to severe damages of flood, should be prioritized for screening, and mental health services.

The well-being of Iranian adult citizens; is it related to mental health literacy?

Background: Subjective well-being (SWB) is a fundamental concept in the definition of mental health and is a significant health indicator for individuals and societies. Mental health literacy (MHL) is a modifiable variable with known effects on mental health, but its relationship with SWB is not recognized. In this study, the SWB is measured, and its relationship to MHL is investigated. Methods: In this cross-sectional study conducted in Iran in 2019, 1,682 individuals participated using a convenient sampling method. Participants with a basic ability to use internet were included. A simple online form was used to collect data. SWB and MHL were measured with three questionnaires: WHO-5 Well-Being Index, Mental Health Literacy Scale, and Mental Health Positive Knowledge. Results: Most of the participants were young (mean age 25.99, SD 9.14), female (71.9%), and had a university degree (78.5%). The mean SWB was 50.19 out of 100 (SD 20.92). More than half of the participants (50.4%) were screen-positive for clinical depression regarding their low well-being. Significant but very small correlations were detected between SWB and both MHL measures. Conclusion: The well-being of half of the educated Iranian citizens who participated in this study was poor and lower than previous measurements. No strong correlation is detected between SWB and MHL measures in this study. This suggests that people's well-being cannot be improved by merely implementing mental health educational programs.

Randomized controlled trial for the efficacy of three versus five sessions of grief counseling on the psychological aspects following COVID-19 bereavement: A study protocol.

Background: During the COVID-19 pandemic, many people have experienced traumatic losses and therefore are at risk of developing complicated grief regarding the restrictions on the performance of routine mourning rituals. This study is a randomized controlled trial for assessing the efficacy of three versus five sessions of grief counseling on grief intensity, psychological distress, and quality of life of grief among bereaved people due to COVID-19. Methods: A total of 120 bereaved people, due to COVID-19, will be enrolled in this multi-center randomized controlled trial after assessment for inclusion and exclusion criteria. Following the informed consent procedure, participants will be allocated into two groups equally by the Stratified Balanced Block Randomization, one of them delivering a three-session grief counseling intervention and the other delivering a five-session grief counseling intervention. The intervention will be delivered by trained psychologists via in-person individual sessions. The primary outcome is grief intensity, and the secondary outcomes are psychological distress, quality of life, and satisfaction of the participants. These outcomes will be measured by the Grief Intensity Scale (GIS), the General Health Questionnaire-28 (GHQ-28), the Short Form Health Survey-12 (SF-12), and the Client Satisfaction Questionnaire (CSQ-8), respectively. The assessments will be done at three time points, one before the intervention and the others 1 month and 3 months after the intervention. The data will be analyzed using the SPSS V.18 and Stata V.11 software. The analysis approach will be "intention to treat." Discussion: Results of this study can be applied for selecting the most suitable intervention leading to the prevention of complicated grief and the maintenance and promotion of the mental health of bereaved people due to COVID-19. Clinical trial registration: [irct.ir], identifier [IRCT20200505047305N1].

War, immigration and COVID-19: The experience of Afghan immigrants to Iran Amid the pandemic.

Introduction: Afghanistan's domestic upheaval following the Taliban's invasion leads to massive displacement of its population. The number of Afghan refugees in Iran has dramatically increased since the Taliban's takeover of Afghanistan in August 2021. Multiple pre-and post-migratory traumatic experiences affect immigrants' physical, psychological, social, and economic wellbeing. The coronavirus outbreak, considered a traumatic experience in human life in the 21st century, added to their problems in Iran and exposed them to new challenges. This qualitative study aimed to investigate their experiences early before, during, and after immigration and the pandemic's challenges to their lives in Iran. Methods: In the present qualitative study, ten Afghan residents living in Iran who immigrated to Iran legally or illegally since the summer of 2021 and the last year after the second Taliban invasion were selected via purposive sampling. A semi-structured interview was applied to gather the data, and the data were analyzed through Braun and Clarke's thematic analysis method. Results: Ten male participants with a mean age of 26 y/o were interviewed. Their residence in Iran was between 20 days and 8 months. Four main themes were extracted. The first theme, the Tsunami of suffering, represents a disruption of the normal flow of life. Six subthemes, including loss, being near death, insecurity, sudden hopelessness, leaving the country involuntarily, and reluctance to explore underlying emotions, are included in this category. The second one, Lost in space, describes the participant's attempt to leave Afghanistan following the extensive losses and violent death threats. Their experiences are categorized into four subthemes: the miserable trip, encountering death, life-threatening experiences, and being physically and verbally abused. The third theme, with its five subthemes, try to demonstrate the participants' experiences after getting to their destination in Iran. The last one, Challenges of the COVID-19 explained the experience of Taliban return, war trauma, running away, and living as a refugee or immigrant coincided with the COVID pandemic. Discussion: Our interviewees explained multiple and successive traumatic experiences of war, migration, and the pandemic. The central clinical features of survivors are fears of losing control, being overwhelmed, and inability to cope. They felt abandoned because not only lost their family support in their homeland but could not also receive support in Iran due to the pandemic-related social distancing and isolation. They were dissociated and emotionally numb when describing their experience, which is a hallmark of experiencing severe, unprocessed traumas. Conclusion: Gaining a better understanding of Afghan refugees lived experiences may help provide them with better social and health care support. Proper mental and physical healthcare support and de-stigmatization programs may reduce the impact of multiple traumas on their wellbeing.

Mental Health Literacy and Mental Health Information-Seeking Behavior in Iranian University Students.

Background: Inadequate Mental health literacy (MHL) is a problem worldwide. Research is limited in developing countries and about positive MHL. This study measured the disease-oriented MHL and positive MHL and investigated their association. In addition, this study explored the mental health information-seeking behavior among undergraduate students in Iran. Methods: This study recruited undergraduate students of Tehran public universities through multistage stratified random sampling to undertake an analytical cross-sectional study. MHL was measured using Mental Health Literacy Scale (MHLS) and Mental Health Positive Knowledge (MHPK). Participants' most used mental health information sources and their trust in them were also inspected. Results: A total of 543 students participated in this study. On average, the participants achieved about 65% of the total possible MHLS score, and 71% of participants showed sufficient MHPK score. The "internet" was the most used source for receiving and searching for mental health information. The most trusted source was "health care staff". This study detected no correlation between disease-oriented MHL and positive MHL. Conclusions: Mental health literacy of Iranian students still seems to be insufficient. As disease-oriented MHL and positive MHL were not correlated, specific educational interventions for each domain are needed. Although the internet is the main source of mental health knowledge, the trust of student in it is low. This issue should be taken into consideration in designing online educational interventions.

Developing an Educational Package to Improve Attitude of Medical Students Toward People With Mental Illness: A Delphi Expert Panel, Based on a Scoping Review.

Introduction: The importance of stigma toward patients with mental illness in medical students as future physicians cannot be overemphasized. There is currently no formal training to reduce stigma toward mental illness in medical students in their educational curriculums in Iran like most other low and middle income countries. Therefore, aiming to provide a practical and effective training package focused on reducing stigma toward patients with mental illness in medical students, the current study conducted, as an expert panel with Delphi method, based on a scoping review, to develop an education package to improve attitude of medical students toward patients with mental illness. Materials and Methods: We surveyed the available international databases including PubMed, Google Scholar, Scopus, PsycINFO, Tripdatabase, Web of Science, Cochrane Database of Systematic Reviews as well as Persian databases including Iranmedex, SID, Irandoc and Magiran in February and March 2020. After an extensive review of related resources, 13 articles met our inclusion criteria. Then, we extracted the related data including type and duration of the interventions, sample size, mean and standard deviation of stigma scores before and after interventions. To develop the package among the included interventions, we asked 16 experts in psychology, psychiatry, and social medicine to rate the interventions based on a number of variables such as effectiveness, feasibility and applicability in a Delphi process. Results: The selected intervention in Delphi method with consensus of experts included a set of four sequential interactive interventions: showing a movie and discussing it, psychiatric training including contact with people who affected psychiatric disorders, social communication with people who affected psychiatric disorders, and group discussion on defining stigma and personal experiences. Conclusion: In the present study, we recommend a set of interventions to reduce stigma toward patients with mental illness among medical students in the form of a package of combined, interactive and sequential interventions that have been previously been shown to be effective in reducing stigma related to mental illness. We expect that implementation of these interventions would reduce mental illness stigma in medical students; which needs further verification.

Assessment of psychiatrists' approaches regarding disclosure of psychiatric disorders to their patients: a qualitative study.

Background: Diagnosis disclosure is the result of a shift in medical approaches from traditional paternalism to participatory and patient-centered decision making. Disclosure of psychiatric diagnosis remained uncommon and controversial. Giving information about psychiatric illnesses is very complicated, and it is affected by several factors. While clinical guidelines provide a clear pathway for treating patients, in practice, the treatment of patients is influenced by cultural and social factors. The aim of the current study was a qualitative assessment of psychiatrists' approaches regarding the disclosure of psychiatric disorders to their patients. Methods: The current study was conducted with a qualitative approach. The participants were purposefully selected psychiatrists from three medical universities in Tehran, Iran. The data gathered using the semi-structured interview method. Sixteen interviews with 14 psychiatrists were conducted. Data were analyzed using thematic analysis. Results: Psychiatrists decide to disclose the diagnosis based on several factors. We summarized these factors in a central theme, passive situational decision making based on paternalism and displacement of responsibility. It has two subthemes, including "passive and situational decision making" and "paternalism and displacement of responsibility." Each theme presented by detailed quotations. Conclusion: The results of this study showed that psychiatrists did not actively disclose the diagnosis name to patients. Diagnosis disclosure was influenced by several factors, such as the certainty about the diagnosis and the severity of the disease. This passive approach does not respect the patient's rights. The paternalistic nature of this approach mandates psychiatrists to consider themselves as the responsible perosn for their patients' welfare.

The experience of patients with bipolar disorder from diagnosis disclosure: A qualitative study.

Background: Disclosure of the diagnosis is an essential part of the treatment process and an important part of patient rights. However, it can be a very stressful experience, especially in mental health disorders. Patients with bipolar disorder have a unique experience of receiving and managing their diagnosis. The objective of the current study was to explore the experience of patients with bipolar disorder of diagnosis disclosure. Methods: This was a qualitative study. Participants were recruited from patients who knew their disorder's name using purposive sampling method. The inclusion criteria were being diagnosed by a psychiatrist as having bipolar disorder and the disclosure was conducted by a psychiatrist. Sixteen semi-structured, in-depth interviews were conducted with twelve patients. Data were analyzed using thematic content analysis. Results: Patients received their diagnosis name in three steps including Wandering in Unknowns, Limited Brightness and Reaching to a Relative Insight. Patients believed that disclosure of the diagnosis was not accompanied by enough information. Conclusion: The disclosure of diagnosis in patients with bipolar disorder without providing enough information is stressful and is not helpful in empowering these patients. Based on our results, disclosure of diagnosis to patients with bipolar disorder was not conducted with enough information and patients had problems for understanding their symptoms and treatments.

Validity and reliability of Persian translation of the Borderline Evaluation of Severity over Time (BEST) questionnaire.

Background: Borderline Evaluation of Severity over Time (BEST) is one of the self-reported tools for evaluation of the severity and track the response of treatment of borderline personality disorder. The present study evaluated the validity and reliability of Persian Translation of the Borderline Evaluation of Severity over Time (BEST) Questionnaire and to compare it with a semi-structured clinical interview for DSM-IV axis II (SCID-II). Methods: The questionnaire was translated into Persian and then, the content and face validities of the questionnaire were determined. The translated BEST questionnaire and SCID-II were conducted on 33 outpatients and 32 hospitalized patients with diagnosis of borderline personality disorder and 30 patients' companions. Forty-five patients completed the questionnaire again in an interval between 7 to 45 days. The data were analyzed using exploratory factor analysis, paired sample t-test, and the Pearson correlation coefficient and Cronbach's α coefficient. Results: This study evaluates the content validity, face validity, and criterion validity and reliability of the Persian version of the BEST Questionnaire. The mean scores of the BEST questionnaire were 45.6, 39.2, and 24.3 in in-patients, outpatients, and controls, respectively (p=0.001). The mean scores of the BEST questionnaire were 43.7 in the first evaluation, and 41.4 in the second one (r=0.619, p<0.001). Cronbach's α coefficient was 0.761, and it reached to 0.898 after omitting items 13 to 15. The questionnaire had a two-factor structure, including internal turmoil and the disturbance in interpersonal relationships. Conclusion: The Persian version of the BEST Questionnaire has a high face and content validity, high criterion validity, moderate to high reliability, and an acceptable two-factor structure.

The efficacy of narrative exposure therapy in a sample of Iranian women exposed to ongoing intimate partner violence-A randomized controlled trial.

OBJECTIVE: The mental health needs of women affected by intimate partner violence (IPV) and living under continuous domestic violence are currently not well understood. The present study investigates the feasibility and efficacy of narrative exposure therapy (NET), compared with commonly used counselling (treatment-as-usual, TAU), in a group of currently IPV-affected women in Tehran, Iran. METHOD: Forty-five IPV-affected women with a diagnosis of post-traumatic stress disorder (PTSD) were randomized to 10 to 12 sessions of either NET (n = 24) or TAU (n = 21). Primary outcome measures, including PTSD, depression, and perceived stress symptoms, were examined at pretreatment and 3- and 6-month follow-ups. IPV experiences, general lifetime traumatic events, childhood adversities, borderline symptoms, and daily functioning impairment were also inspected. RESULTS: NET participants showed a significantly greater symptom reduction in comparison with the TAU group in PTSD, depression, and perceived stress at both follow-ups. Improvement in daily functioning and reduction of IPV experiences and borderline symptoms at 3- and 6-month follow-ups were pronounced but not significantly different between the two treatment groups. CONCLUSION: IPV-affected women living under continuous threat and violence would benefit from trauma-focused interventions such as NET.

Domestic violence against women as a risk factor for depressive and anxiety disorders: findings from domestic violence household survey in Tehran, Iran.

Domestic violence (DV) especially intimate partner violence is a global health problem responsible for significant part of burden of diseases in women. Mental health problems such as depression and anxiety are possibly results and resulted in IPV. To investigate correlation between IPV and depression and anxiety among married women, in a household survey of married women in Tehran, Iran, at summer 2011, we recruited 615 samples with cluster sampling method and they are directly asked about experience of 23 different types of physical and non-physical IPV during marital life and last 12 months. Depression and anxiety were assessed by Beck depression inventory II (BDI) and Beck Anxiety inventory (BAI). Multinominal regression model was used to assess the independent relationship of factor on IPV. Mean (±SE) age and duration of marriage were 42.6 ± 0.9 and 22 ± 0.8, respectively. Non-physical violence and physical violence during marital life reported in 77.2 and 35.1 %. Clinically significant depression and anxiety was reported in 15.3 and 32.7 % of women, respectively. The odds ratio (95 % CI) of clinically significant depression and anxiety in DV victims were 5.8 (2.3-14.6) and 2.6 (1.6-4.3). DV as a social factor is significantly correlated factor with depression and anxiety. Comprehensive view and collaborative work to detect and address social determinants of mental illness like DV is a crucial point in mental health promotion programs.

Primary health care physicians' approach toward domestic violence in Tehran, Iran.

BACKGROUND: Primary health care physicians (PHCPs) are the first in the clinic to detect and help victims of intimate partner violence (IPV). Therefore, their attitude and practice toward domestic violence (DV) are important to manage this problem. The aim of current study was to compare the behavior and attitude of PHCPs about DV versus other health risk factors in Tehran, Iran. METHODS: A convenience sample of 220 PHCPs was evaluated. The study was carried out in April 2012. Two self-administered questionnaires were used to identify physicians' beliefs and behaviors on screening and intervention of DV and other health risk factors. All analyses were performed using SPSS version 18.0 (SPSS, Inc. Chicago, IL). RESULTS: One hundred and ninety eight questionnaires were analyzed. PHCPs' mean age was 39.06 (±7.5) years. Participants were just reported 10% screening of regular patients for DV compared with 29% to 48% for other health risk factors. Mean age of PHCPs was not associated with their approach toward the DV. Compared to male physicians, females spared more time for DV victims. Major of physicians (96%) believed that DV is not a private problem and is something that needs to be addressed cautiously. CONCLUSION: The results of this study indicated that DV screening occurs less than that of other health risk factors. Attitude of majority of PHCPs was positive for addressing this problem.

Correlates of mental health service utilization in married women in tehran 2011.

OBJECTIVE: There are disparities in mental health services (MHS) utilization within and between populations and several factors are studied as its potential correlates. Identifying those correlates would help health policy makers to adjust service provision with characteristics of their community. To evaluate demographic, socioeconomic and system correlates of MHS utilization among married women from Tehran, Iran. METHODS: A household survey of 615 married women residents of 22 municipal districts of Tehran selected via a cluster sampling method. All subjects were asked about health services utilization during last one and 12 months as well as need and access for MHS, demographic and socioeconomic factors. Independent correlates of MHS use were determined with logistic regression analysis. RESULTS: Total 615 women, mean±SE age and duration of marital life of 42.6±0.9 and 22±0.8 years, respectively were selected, rate of MHS utilization during last one and 12 months were 5.2% and 10.1% respectively. 23.6% of women reported having mental illness and 19.3% and 17.9% had need for MHS and access to outpatient health services, respectively. Logistic regression models showed that need for MHS (OR:5.25, 95%CI:2.7-10.1), access to outpatient services (OR:2.17, 95%CI:1.04-4.52), smoking (OR:3.4, 95%CI:1.16-10.2) and crowding index (OR:0.69, 95%CI:0.48-0.99). CONCLUSIONS: Rate of MHS utilization in women are low considering the near to estimated rate of perceived illness. Bridging the gap between perceived illness and need for services, then providing better access to services in areas with higher crowding index and higher rates of smoking in residents should considered in any mental health promotion programs. DECLARATION OF INTEREST: None.

Effectiveness of meta-cognitive and cognitive-behavioral therapy in patients with major depressive disorder.

OBJECTIVE: The present study aimed to compare the effectiveness of metacognitive therapy (MCT) and cognitive-behavior therapy (CBT) in treating Iranian patients with major depressive disorder (MDD). METHODS: Thirty three outpatients meeting DSM-IV-TR criteria for MDD without any other axis I and II disorders were randomly assigned to one of three treatment conditions, i.e. MCT, CBT and pharmacotherapy. The Beck Depression Inventory-II-Second Edition (BDI-II), Beck Anxiety Inventory (BAI), Ruminative Response Scale (RRS) and Dysfunctional Attitude Scale (DAS) were administered for pre-treatment, post-treatment and follow-up. Data were analyzed by repeated measures analysis of variance (ANOVA). RESULTS: Based on repeated measures ANOVA, all the participants demonstrated improvement in depression, anxiety, dysfunctional attitude and ruminative response. Based on percentage results, all the patients in MCT and CBT groups showed significant improvement at post-treatment phase. CONCLUSIONS: MCT and CBT were more effective than pharmacotherapy alone In treatment of MDD. DECLARATION OF INTEREST: None.

Association of angiotensin-converting enzyme polymorphism with coronary artery disease in Iranian patients with unipolar depression.

OBJECTIVES: Major depressive disorder (MDD) is an increasingly recognized risk factor of coronary artery disease (CAD). The aim of this study was to assess the relationship between renin-angiotensin system (RAS) genetic polymorphisms and CAD in a sample of depressed Iranian patients. DESIGN AND METHODS: A total of 191 patients with a history of unipolar depression were enrolled in a case/control study. The presence of MDD was reconfirmed at study entry using DSM-IV criteria and CAD was diagnosed by coronary angiography. Genotyping of six RAS genes polymorphisms was performed by a modified PCR-RFLP method. RESULTS: DD genotype of ACE I/D was independently associated with the incidence of CAD in depressed patients (P=0.011, OR=9.41, 95% CI: 1.68-17.81). Moreover, serum creatinine (P=0.033, OR=11.91, 95%CI: 7.23-15.62) was an independent predictor of CAD among depressed individuals. CONCLUSION: ACE I/D polymorphism may play a major role in the development of CAD amongst Iranian depressed patients.

How Iranian lay people in three ethnic groups conceptualize a case of a depressed woman: an explanatory model.

OBJECTIVE(S): Although depression is a major public health problem, little is known about lay people's views of this subject in Iran. The aim of this study was to explore how depression in women is viewed among lay people in three major ethnic groups--Kurd, Turk, and Fars. DESIGN: Participants were selected from public urban healthcare centers. Four focus group discussions were conducted for each of the three ethnic groups and classified by level of education from three locations, in the capital city (Tehran), west (Ilam), and the northwest (Tabriz) of Iran. Twelve focus groups; 38 men and 38 women have been conducted by using a case vignette describing a woman with major depression. RESULTS: Depression symptoms were perceived as a temporary phenomenon. It was regarded as a colloquial term for feeling blue, mostly related to external stressors (social model). The common terms used in all ethnic groups were depression, and nerve/soul distress. Environmental cause and war were considered as external causes of the symptoms, and emotional factors, cognition distortion, and biological reasons, as internal factors. The participants believed it was necessary to seek help from religion, family and friends, positive thinking, and distraction from social problems, besides consultations with psychologists as counselors. Medication was often seen as the last resort. Stigma was mentioned as an important factor that makes people avoid visiting psychiatrists. CONCLUSION: These data may have implications for mental healthcare practice, especially for the approach to diagnosis of depression. Moreover, there is a need for developing and integrating gender-relevant and cultural indicators in the existing national mental health systems in Iran.