Depression, anxiety and quality of life of Afghan women living in urban areas under the Taliban government: a cross-sectional study

Abstract

Objectives

According to the World Health Organization, depression is a common mental health illness that is characterised by a persistent feeling of sadness and loss of interest. The present study examined the association of two mental health variables (ie, depression, anxiety) with quality of life (QoL) and the sociodemographic characteristics of Afghan women living in urban areas under the rule of Taliban government in Afghanistan.

Design

Cross-sectional study administered between 10 November 2021 to 25 December 2021 among women.

Setting

Across major provinces of Afghanistan (Herat, Mazar-e-Sharif, Kabul and Samangan).

Measurements

Data were collected using a pretested structured questionnaire. Data entry was carried out using Microsoft Excel 2016. And then exported to IBM SPSS V.26 for Microsoft Windows. Logistic regression models were used to examine the association of depression, anxiety with QoL and sociodemographic characteristics among women (N=438).

Results

The prevalence of depression symptoms was 80.4%, and the prevalence of mild to extremely severe anxiety was 81.0%. Depression symptoms among Afghan women were associated with being older, having more children, lower education level, other individuals’ bad behaviour, bad events experienced in the past month, and feeling physically ill. Multiple regression analysis indicated that low monthly household income (adjusted OR, AOR 2.260; 95% CI 1.179 to 4.331, p=0.014) poor physical domain of QoL (AOR 4.436; 95% CI 1.748 to 11.256, p=0.002) and poor psychological domain of QoL (AOR 23.499; 95% CI 7.737 to 71.369, p<0.001) were significantly associated with depression.

Conclusion

The prevalence of depression was high among women living under the government of the Taliban in Afghanistan. Considering the high prevalence of depression, anxiety and their impact on QoL and the overall quality of healthcare services, international health organisations should implement programmes for regular screening of depression and anxiety, and there should be psychological counselling services available for vulnerable women living under the government of the Taliban.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This study examined the association of depression, anxiety with quality of life and the sociodemographic characteristics of Afghan women.

• Validated questionnaires and scales were used for the study.

• The findings provided estimates of depression and anxiety among Afghan women and the association of these mental health disorders with quality of life but all the data were self-report and subject to a range of methods biases.

• The study sample was not representative of all Afghan women.

Introduction

According to the World Health Organization (WHO), depression is a common mental health illness that is characterised by a persistent feeling of sadness and loss of interest.¹ Symptoms include fatigue, poor concentration, and disrupted sleep and appetite.¹ The WHO also states that nearly 5% of adults worldwide suffer from depression. It also notes that depression can limit an individual’s capacity to function and live a fulfilling life. Life events and difficulties such as the death or loss of a loved one, financial issues, conflicts, and poor social support can trigger depression.² According to the WHO, depression is a leading cause of disability and disproportionately affects women.¹ Consequences can include suicide and self-destructive behaviours. In relation to gender differences in depression, a group of researchers in China found that genetic factors and the differential heritability of depression between men and women, may be one of the reasons why women are more susceptible to depression than men.³ Moreover, women can experience depression during pregnancy,⁴ but also, according to Guo et al, 1 in 20 women in the USA of reproductive age who are not pregnant also suffer from major depression.⁵

Anxiety is another common mental health disorder.⁶ It is characterised by feelings of tension and anxious thoughts, as well as elevated blood pressure.⁷ Normally, anxiety is a natural emotion needed for survival. However, excessive anxiety, particularly in the absence of any threat, is considered a mental health illness.⁶ Cognitive symptoms include difficulty speaking, poor concentration, poor memory, and confusion.⁸ Moreover, physiological symptoms include shaking, sweating, dizziness, nausea and increased heart rate.

The WHO defines the quality of life (QoL) as an individual’s view of their position in life in relation to their goals, standards, and concerns and within the framework of their culture and value systems.⁹ QoL describes the overall well-being of an individual including the positive and negative aspects of their life.¹⁰ These aspects include physical, mental, and spiritual health as well as education status, safety, freedom, relationships, and wealth. QoL is becoming more of a subjective individual perception and less objective.¹¹

Nearly 50% of those with depression are also diagnosed with anxiety disorders.¹² Anxiety can also run across generations. In a Swedish study, researchers found that women whose mothers were diagnosed with anxiety were more than twice as likely to experience anxiety disorders themselves.¹³ Moreover, if both the mother and grandmother had an anxiety disorder, the odds of a child being diagnosed with anxiety increases threefold.¹⁴ Anxiety and depression are highly comorbid mental health disorders, and their symptoms commonly overlap.¹⁴ Among the causes of depression are stressful events, family history, specific personality traits (eg, neuroticism), loneliness, and childbirth.¹⁵ On the other hand, factors such as traumatic life events or underlying health issues can lead to anxiety disorders.¹⁶ A national survey on depression and anxiety in Afghanistan (where the present study was carried out), reported that the Afghan population was heavily exposed to traumatic events, with 64.7% having personally encountered at least one traumatic life event.¹⁷ A study, conducted by Najafipour et al in Iran in 2021, reported that the likelihood of developing anxiety and depression was 2.26 and 2.56 times higher among women compared with men, respectively.¹⁸ Najafipour et al also noted that research into QoL can be diverse regarding research groups, designs, and measures.

QoL is mainly studied in developed countries. However, the cross-cultural significance of QoL is not clear. According to a global survey in 2020, QoL was higher among older male adults compared with older female adults across many nations.^{19 20} In relation to the factors affecting QoL, it has been found that socioeconomic factors play an important role in the QoL such that the QoL among individuals in low-income and middle-income countries is significantly impacted by a lack of financial support.²¹ Another study noted that QoL is lower among individuals with anxiety and depression even before the onset of depression.²² However, their QoL further drops with the onset of mental health disorders.²² In relation to the factors affecting QoL among patients with depression, Cho et al reported that ‘older age, lower level of education, lower income, worse subjective perception of health, unemployment, obesity and mental health struggles’ were related to the lower QoL among patients experiencing depression.²³

According to the WHO, 1 in 10 individuals living in conflict zones experience moderate or severe mental health disorders and there is still a lack of awareness concerning mental health in many countries.²⁴ After two decades of war, the Taliban returned to power in Afghanistan in 2021.²⁵ Due to such conflicts and wars, the mental health of Afghan youth has been negatively impacted. A 2021 report noted that after decades of war and due to the current political situation in Afghanistan, immediate attention and investment is required for mental health.²⁶ Moreover, due to the social norms in Afghanistan, women and girls face additional obstacles. A cross-sectional study, conducted in 2022, found that gender plays a role in the mental health of high school students such that girls experienced higher levels of anxiety and depression in comparison to boys.²⁷ Another recent 2022 study examining mental health and suicidality among Afghan university students reported that 69.7% had clinical signs of depression after the takeover of Taliban in 2021.²⁸ Based on a report by the Canadian Women for Women in Afghanistan, in post-Taliban era in 2002, the prevalence of depression was reported to be 73% among Afghan women. This report also noted that 86% of women had significant anxiety symptoms.²⁹ Another study conducted in 2021 reported that 79.1% of Afghan women were depressed before the fall of the government to the Taliban.³⁰

Women continue to face many obstacles and challenges in their pursuit of equality. In many parts of the world, women are still denied basic rights and freedoms, including the right to education, the right to work, and the right to vote, as well as subjugation to men within family settings. Even in more progressive societies, women continue to face discrimination and inequality in the workplace, in politics, and in their personal lives.³¹ When the Taliban government took over in 2021, the country faced an economic, food, and health crisis. The retreat of international donors and increased sanctions by the international community led to the collapse of the economy, high unemployment, food insecurity, and malnutrition. Moreover, under the Taliban government, women have been marginalised.

With more than half of Afghanistan’s population now living below the poverty line, the situation is even worse for girls and women.³² Under the Taliban government, women are limited in education, employment, mobility, political participation, healthcare, and public presence.³³ These conditions can exacerbate already existing mental health disorders among women. Along with other factors, COVID-19 is likely to have had a negative impact on women’s mental health. With many schools and daycare centres closed, women had to take on additional responsibilities such as caring for children and/or elderly family members, often while trying to work from home. This increased workload can lead to feelings of exhaustion, frustration and burn-out, all of which can take a toll on mental health.³⁴

Many studies have emphasised the importance of mental health.^35–37 However, under the rule of the Taliban government in Afghanistan, no previous study has examined depression, anxiety and QoL all together and specifically among women under the rule of Taliban. The present study is the first to investigate depression, anxiety and QoL among women simultaneously. It also examined the factors associated with depression, anxiety and QoL. Finally, the study examined the association of the two mental health variables (depression, anxiety) with QoL, and the sociodemographic characteristics of Afghan women living under the rule of Taliban in urban areas.

Methods

Participants, study design and sample

A cross-sectional study was conducted by the Afghanistan Centre for Epidemiological Studies. The study participants (N=438) were women aged 15–70 years and were recruited from urban areas in major provinces (Herat, Mazar-e-Sharif, Kabul and Samangan) of Afghanistan. Participants were interviewed face-to-face and their answers were recorded by the data collectors. The eligibility criteria to participate in the present study were: (1) being female; (2) being 15 years old or older; (3) being able to understand the Dari language and (4) providing written or verbal informed consent for adults (aged 18 years or above) from themselves and for adolescents (aged 15–18 years) from their parents. The target sample size of participants was determined using the formula N=Zα2P (1−P)/d², in which α=0.05 and Zα=1.96, and the estimated acceptable margin of error for proportion d was 5%. The proportion of women with depression was estimated at 80%, based on the available literature.³⁰ The sample size was calculated using OpenEpi software (V.3.01).

Instruments

A survey consisting of four subsections was used in the present study. The subsections assessed: sociodemographics, depression, anxiety, and QoL.

The sociodemographic section included questions concerning age, height, weight, marital status, number of children, province of residency, educational level, monthly household income, occupation, individual behaviour (how good or bad other people behaved with the participants during the past month), Taliban’s behaviour (how good or bad the Taliban forces behaved with the participants during the past month), whether the participant experienced a bad event in the past month (ie, any action or event that happened during the past month which caused the participant to feel down or depressed; this was left up to the participants to interpret what the bad event was), and feeling physically ill during the past month.

In order to assess participants’ symptoms of depression, the Dari version of the 20-item Centre for Epidemiological Studies Depression Scale (CES-D) was used.^{38 39} The CES-D comprises three subscales (negative items, positive items, and interpersonal relationships). All of the items (eg, ‘I felt everything I did was an effort’) are scored from 0 (‘rarely or none of the time/less than 1 day during the past week’) to 3 (‘Most of all of the time/5–7 days during the past week’). The scores range from 0 to 60. The standard cut-off score was used as follows: a score between 0 and 15 is considered as normal. Participants with a score higher than 15 are considered as having depression symptoms. Cronbach’s alpha in the present study was 0.87.

In order to assess participants’ symptoms of anxiety, the 14-item subscale of the Dari version of the Depression, Anxiety, Stress Scale-42 (DASS-42) was used.⁴⁰ All of the items (eg, ‘I had a feeling of faintness’) are scored from 0 (‘did not apply to me at all’) to 3 (‘applied to me very much, or most of the time’). The scores range from 0 to 42 which indicate one of the five states of anxiety. A score between 0 and 7 is considered as normal; 8 and 9 indicates mild anxiety; 10 and 14 indicates moderate anxiety; 15 and 19 indicates severe anxiety; and a score of 20 or higher indicates extremely severe anxiety. Cronbach’s alpha in the present study was 0.83.

In order to assess participants’ QoL, the Dari language validated version of the WHO Quality of Life-BREF (WHOQOL-BREF-26) was used.⁴¹ The WHOQOL-BREF-26 comprises four subscales (physical health domain, psychological health domain, social relationships domain, and environment domain). All of the items (eg, ‘To what extent do you feel that physical pain prevents you from doing what you need to do?’) are scored from 1 (not at all) to 5 (an extreme amount). In order to make scores comparable with the WHOQOL-100, raw scores were converted into the transformed score to range within 0–100. For each subscale of the WHOQOL-BREF 26, a total score of less than 46 indicates low QoL; 46–65 indicates moderate QoL; and higher than 65 indicates high QoL.⁴² Cronbach’s alpha in the present study was 0.85.

Analysis

Data entry was carried out using Microsoft Excel 2016. The analysis was performed with the IBM SPSS V.26.0 for Windows. Descriptive statistics included means, SDs, frequencies and percentages. Associations between variables were evaluated using χ² tests. Multiple regression analysis was used to examine independent sociodemographics, subgroups of the QoL, and anxiety with the presence of depression. All of the variables with a p-value less than 0.05 were considered as significant.

Patient and public involvement statement

Patients or the public were not involved in the design, conduct, reporting, and dissemination plans of the research.

Results

Sociodemographics

Two-thirds of the participants’ body mass index were in normal weight range (72.4%). More than half of the participants were single (54.3%). Almost half of the participants reported that their monthly household income was less than the equivalent of US$50 (54.3%). Almost two-thirds of the participants were unemployed (69.2%) (table 1).

Table 1.

Sociodemographic characteristics in the study sample (N=438)

Characteristic	Categories	N	%
Age group	15–24 years	245	55.9
	25–70 years	193	44.1
BMI	Underweight	31	7.1
	Normal weight	317	72.4
	Overweight	69	15.8
	Obesity	21	4.8
Marital status	Single	238	54.3
	Married	175	40.0
	Widow/divorced	25	5.7
No of children	None	274	62.6
	1–5	120	27.4
	5–12	44	10.0
Province	Herat	91	20.8
	Kabul	113	25.8
	Mazar-e-Sharif	117	26.7
	Samangan	117	26.7
Education level	Illiterate	77	17.6
	Primary school	19	4.3
	Secondary school	20	4.6
	High school	97	22.1
	University	255	51.4
Monthly household income	Less than US$50	238	54.3
	US$50–US$100	89	20.3
	US$100–US$200	74	16.9
	US$200–US$300	32	7.3
	More than US$300	5	1.1
Occupation	Employed	135	30.8
	Unemployed	303	69.2
Individuals’ behaviour in the past month	Good	339	77.4
	Bad	99	22.6
Taliban’s behaviour in the past month	Good	162	37.0
	Bad	276	63.0
Experienced a bad event in the past month	Yes	314	71.7
	No	124	28.3
Feeling physically ill in the past month	Yes	104	23.7
	No	334	76.3
Total		438	100.0

BMI, body mass index.

The proportions of participants with a high QoL in the four domains were as follows: physical health domain (13.0%), psychological health domain (11.2%), social relationship domain (14.4%), and environment domain (3.7%) category (figure 1).

Figure 1.

Responses to Quality of Life domain questions by participants.

Four-fifths of the participants had symptoms of depression (80.4%). Symptoms of depression were significantly related to (1) age (older women more likely to depressed), (2) number of children (women with more children more likely to be depressed), (3) educational level (women with lower education more likely to be depressed), (4) other individuals’ behaviour (women who were treated badly by other Individuals in the past month more likely to be depressed), (5) bad events (women experiencing a bad event in the past month more likely to be depressed), and (6) feeling physically ill (women feeling physically ill more likely to be depressed compared with those who did not) (table 2).

Table 2.

Association of depression with participants sociodemographic characteristics (n=438)

Characteristic	Categories	Mental health		p-value
		Normal	Depressed
		N (%)	N (%)
Age group	15–24 years	58 (23.7)	187 (76.3)	0.017
	25–70 years	28 (14.5)	165 (85.5)
BMI	Underweight	7 (22.6)	24 (77.4)	0.842
	Normal weight	64 (20.2)	253 (79.8)
	Overweight	12 (17.4)	57 (82.6)
	Obesity	3 (14.3)	18 (85.7)
Marital status	Single	54 (22.7)	184 (77.3)	0.120
	Married	30 (17.1)	145 (82.9)
	Widow/divorced	2 (8.0)	23 (92.0)
No of children	None	64 (23.4)	210 (76.6)	0.018
	1–5	19 (15.8)	101 (84.2)
	5–12	3 (6.8)	41 (93.2)
Province	Herat	22 (24.2)	69 (75.8)	0.120
	Kabul	14 (12.4)	99 (87.6)
	Mazar-e-Sharif	27 (23.1)	90 (76.9)
	Samangan	23 (19.7)	94 (80.3)
Education level	Illiterate	6 (7.8)	71 (92.2)	0.007
	Primary school	1 (5.3)	18 (94.7)
	Secondary school	4 (20.0)	16 (80.0)
	High school	18 (18.6)	79 (81.4)
	University	57 (25.3)	168 (74.7)
Monthly household income	Less than US$50	37 (15.5)	201 (84.5)	0.050
	US$50–US$100	17 (19.1)	72 (80.9)
	US$100–US$200	20 (27.0)	54 (73.0)
	US$200–US$300	11 (34.4)	21 (65.6)
	More than US$300	1 (20.0)	4 (80.0)
Occupation	Employed	24 (17.8)	111 (82.2)	0.514
	Not employed	62 (20.5)	241 (79.5)
Individuals’ behaviour in the past month	Good	79 (23.3)	260 (76.7)	<0.001
	Bad	7 (7.1)	92 (92.9)
Taliban’s behaviour in the past month	Good	38 (23.5)	124 (76.5)	0.123
	Bad	48 (17.4)	228 (82.6)
Experienced a bad event in the past month	Yes	44 (14.0)	270 (86.0)	<0.001
	No	42 (33.9)	82 (66.1)
Feeling physically ill in the past month	Yes	11 (10.6)	93 (89.4)	0.008
	No	75 (22.5)	259 (77.5)
Total		86 (19.6)	352 (80.4)

BMI, body mass index.

Approximately four-fifths of the participants were found to have mild to extremely severe level of anxiety (81.0%). More specifically, 19.0% had no anxiety at all, 6.2% had mild anxiety, 22.6% had moderate anxiety, 21.7% had severe anxiety, and 30.5% had extremely severe anxiety. Symptoms of mild to severe anxiety were significantly related to (1) age (older women more likely to have anxiety), marital status (single women less likely to have anxiety), province (women living in Kabul more anxious than those living in Mazar-e-Sharif), educational level (women with lower education more likely to be anxious), occupation (unemployed women less likely to have anxiety), bad events (women experiencing a bad event in the past month more likely to have anxiety), and feeling sick (women feeling physically ill in the past month more likely to have anxiety than those who did not) (table 3).

Table 3.

Association of anxiety with participants sociodemographic characteristics (N=438)

Characteristic	Categories	Mental health		p-value
		Normal	Anxious
		N (%)	N (%)
Age group	15–24 years	33 (24.4)	102 (75.6)	0.011
	25–70 years	10 (11.0)	81 (89.0)
BMI	Underweight	4 (21.1)	15 (78.9)	0.962
	Normal weight	32 (19.5)	132 (80.5)
	Overweight	5 (16.1)	26 (83.9)
	Obesity	2 (16.7)	10 (83.3)
Marital status	Single	35 (24.0)	111 (76.0)	0.037
	Married	7 (10.4)	60 (89.6)
	Widow/divorced	1 (7.7)	12 (92.3)
No of children	None	36 (23.4)	118 (76.6)	0.050
	1–5	6 (10.2)	53 (89.8)
	5–12	1 (7.7)	12 (92.3)
Province	Kabul	15 (13.4)	97 (86.6)	0.032
	Mazar-e-Sharif	28 (24.6)	86 (75.4)
Education level	Illiterate	0 (0.0)	23 (100.0)	0.029
	Primary school	0 (0.0)	9 (100.0)
	Secondary school	0 (0.0)	3 (100.0)
	High school	9 (17.6)	42 (82.4)
	University	34 (24.3)	106 (75.7)
Monthly household income	Less than US$50	12 (13.5)	77 (86.5)	0.054
	US$50–US$100	7 (13.5)	45 (86.5)
	US$100–US$200	16 (28.1)	41 (71.9)
	US$200–US$300	8 (32.0)	17 (68.0)
	More than US$300	0 (0.0)	3 (100.0)
Occupation	Employed	10 (10.5)	85 (89.5)	0.006
	Unemployed	33 (25.2)	98 (74.8)
Individuals’ behaviour in the past month	Good	35 (22.4)	121 (77.6)	0.051
	Bad	8 (11.4)	62 (88.6)
Taliban’s behaviour in the past month	Good	21 (19.4)	87 (80.6)	0.878
	Bad	22 (18.6)	96 (81.4)
Experienced a bad event in the past month	Yes	22 (15.2)	123 (84.8)	0.048
	No	21 (25.9)	60 (74.1)
Feeling physically ill in the past month	Yes	2 (5.6)	34 (94.4)	0.025
	No	41 (21.6)	149 (78.4)
Total		43 (19.0)	183 (81.0)

BMI, body mass index.

Almost 9 in 10 participants who self-rated their QoL as very poor had depression symptoms (86.1%). Over 9 in 10 participants with low QoL in the physical domain had depression symptoms (93.4%). Over 9 in 10 participants with low QoL in the psychological domain had depression symptoms (95.3%). Having depressive symptoms was found significantly associated with all of the four domains of QoL (table 4).

Table 4.

Association of quality of life of participants with presence of depression (N=438)

Quality of life	Categories	Mental health		p-value
		Normal	Depressed
		N (%)	N (%)
How would you rate your quality of life?	Very poor	5 (13.9)	31 (86.1)	<0.001
	Poor	4 (5.1)	74 (94.9)
	Neither poor nor good	23 (13.9)	142 (86.1)
	Good	39 (31.5)	85 (68.5)
	Very good	15 (42.9)	20 (57.1)
How satisfied are you with your health?	Very dissatisfied	1 (3.2)	30 (96.8)	<0.001
	Dissatisfied	5 (8.5)	54 (91.5)
	Neither satisfied nor dissatisfied	21 (15.0)	119 (85.0)
	Satisfied	31 (25.6)	90 (74.4)
	Very satisfied	28 (32.2)	59 (67.8)
Physical domain	Low	15 (6.6)	213 (93.4)	<0.001
	Moderate	39 (25.5)	114 (74.5)
	High	32 (56.1)	25 (43.9)
Psychological domain	Low	11 (4.7)	225 (95.3)	<0.001
	Moderate	43 (28.1)	110 (71.9)
	High	32 (65.3)	17 (34.7)
Social relationship domain	Low	28 (11.9)	208 (88.1)	<0.001
	Moderate	33 (23.7)	106 (76.3)
	High	25 (39.7)	38 (60.3)
Environment domain	Low	43 (13.6)	273 (86.4)	<0.001
	Moderate	36 (34.0)	70 (66.0)
	High	7 (43.8)	9 (56.2)
Total		86 (19.6)	352 (80.4)

Two-thirds of participants who rated their QoL as very poor (63.2%) had a mild to extremely severe level of anxiety. Over 9 in 10 of participants with low QoL in the physical domain (93.5%) had anxiety symptoms and 93.1% of participants with low QoL in the psychological domain had anxiety symptoms. The presence of mild to extremely severe level of anxiety among the participants of the present study was found significantly associated with all of the four domains of QoL (table 5).

Table 5.

Association of quality of life of participants with presence of anxiety (N=438)

Quality of life	Categories	Mental health		P value
		Normal	Anxious
		N (%)	N (%)
How would you rate your quality of life?	Very poor	7 (36.8)	12 (63.2)	<0.001
	Poor	2 (4.3)	44 (95.7)
	Neither poor nor good	8 (10.0)	72 (90.0)
	Good	14 (23.7)	45 (76.3)
	Very good	12 (54.5)	10 (45.5)
How satisfied are you with your health?	Very dissatisfied	1 (6.7)	14 (93.3)	<0.001
	Dissatisfied	2 (6.3)	30 (93.7)
	Neither satisfied nor dissatisfied	10 (11.9)	74 (88.1)
	Satisfied	9 (17.6)	42 (82.4)
	Very satisfied	21 (47.7)	23 (52.3)
Physical domain	Low	9 (6.5)	130 (93.5)	<0.001
	Moderate	23 (32.9)	47 (67.1)
	High	11 (64.7)	6 (35.3)
Psychological domain	Low	10 (6.9)	134 (93.1)	<0.001
	Moderate	17 (29.3)	41 (70.7)
	High	16 (66.7)	8 (33.3)
Social relationship domain	Low	17 (12.4)	120 (87.6)	0.001
	Moderate	16 (23.9)	51 (76.1)
	High	10 (45.5)	12 (54.5)
Environment domain	Low	19 (11.0)	153 (89.0)	<0.001
	Moderate	21 (42.9)	28 (57.1)
	High	3 (60.0)	2 (40.0)
Total		43 (19.0)	183 (81.0)

Multiple logistic regression analysis was run to see which variables predicted depressive symptoms comprising the following variables: age, marital status, educational level, occupation, income, and QoL domains. Income, physical domain, and psychological domain of QoL were found significant (table 6).

Table 6.

Multiple logistic regression analysis of depression on participants’ characteristics and their quality of life (N=438)

Variable	AOR (95% CI)	p-value
Age	1.032 (0.987 to 1.078)	0.165
Marital status
Unmarried/single	1.556 (0.745 to 3.250)	0.239
Married	Ref.
Educational level
Illiterate	1.914 (0.569 to 6.439)	0.294
Primary/secondary school	2.476 (0.768 to 7.985)	0.129
High school	1.810 (0.850 to 3.857)	0.124
University	Ref.
Occupation
Occupied	0.891 (0.424 to 1.870)	0.760
Non-occupied	Ref.
Income
Low	2.260 (1.179 to 4.331)	0.014
High	Ref.
Physical domain
Low quality of life	4.436 (1.748 to 11.256)	0.002
Moderate quality of life	2.280 (1.072 to 4.849)	0.032
High quality of life	Ref.
Social relationship domain
Low quality of life	0.902 (0.360 to 2.261)	0.825
Moderate quality of life	1.338 (0.584 to 3.062)	0.491
High quality of life	Ref.
Environment domain
Low quality of life	0.452 (0.109 to 1.876)	0.274
Moderate quality of life	0.438 (0.113 to 1.700)	0.233
High quality of life	Ref.
Psychological domain
Low quality of life	23.499 (7.737 to 71.369)	<0.001
Moderate quality of life	4.009 (1.736 to 9.260)	0.001
High quality of life	Ref.

AOR, adjusted OR.

Discussion

In the present study examining Afghan women from urban areas under the rule of the Taliban government in Afghanistan, only 1/10 (9.6%) of the participants reported a normal state of mental health with 9/10 of the total sample reporting symptoms associated with depression and/or anxiety. Previous studies have also found that gender plays a role in the mental health status and that females experience higher levels of mental health disorders compared with males.³¹ More specifically, the findings of the present study indicated that 80.4% of the participants had symptoms of depression. The data also showed that 81.0% of the participants reported symptoms associated with mild to severe anxiety. Additionally, 86.1% of participants who self-reported having very poor QoL had symptoms of depression. The findings showed that 63.2% of participants who self-reported very poor QoL, also showed symptoms of anxiety. The factors that were significantly associated with both depression and anxiety were age (being older), number of children (having more children), education level (being less educated), experiencing a bad event in the past month, and feeling physically ill in the past month.

The estimated percentage of the presence of symptoms of depression in the present study falls within the range reported by WHO (1 in 10 individuals) in the conflict zone areas. However, almost 8 in 10 were reported in the present study which is higher than that reported by the WHO.²⁸ Older age (25–70 years) was more associated with depression symptoms (85.5%) in comparison to younger age (15–24 years) with 76.3%. On the contrary, the findings of an interview survey from 2019 by the Centers for Disease Control and Prevention indicated that 21.0% of the adults aged between 18 and 29 years had depression symptoms compared with the 16.8% of adults aged between 30 and 44 years.⁴³ Increased depression symptoms (93.2%) were found among participants with more children (5–12) compared with participants with less children (1–5) who in turn had a higher percentage of depression symptoms (84.2%) than those with no children (76.6%). This finding contrasts the findings of a cross-sectional study on depression in Chinese adults which reported that each additional child amounted to a 9% lower risk of major depression among women.²³

The presence of depression symptoms was also significantly related to education level. More specifically, participants who were illiterate reported higher depression (92.2%) in comparison to those with university education (74.7%). This finding concurs with a study in Europe where a higher level of education was found to be associated with lower odds of depression.⁴⁴

A highly significant factor related to presence of depression was found to be experiencing a bad event during the past month. More specifically, 86.0% of those who said they experienced a bad event in the past month reported symptoms of depression compared with 66.1% who had depression but did not report experiencing bad event in the past month. Similarly, results from an Italian study among male asylum seekers and refugees found that the number of traumatic events was a risk factor for depression.⁴⁵ Finally, the findings of the present study showed that there was a higher level of depression symptoms among participants who reported they had been physically ill in the past month (89.4%) in comparison to those who did not (77.5%). Similarly, previous studies have shown that chronic disease and pain,⁴⁶ as well as respiratory and digestive symptoms⁴⁷ increase the risk of developing depression.

Among the 81.0% of participants with anxiety symptoms, those who were older (25–70 years) reported a higher percentage of anxiety (89.0%) in comparison to those who were younger (15–24 years) who reported a lower percentage of anxiety (75.6%). This is in contrast with a study in Iran which reported that the prevalence of anxiety was higher among younger women compared with older women.⁴⁸ Moreover, another study conducted during the COVID-19 pandemic found that compared with the middle and old age groups, the younger age group had higher levels of anxiety.^{49 50} Another significant factor associated with anxiety symptoms was marital status where widowed/divorced participants reported the highest percentage of anxiety (92.3%) compared with two other groups (married and single). Married women reported higher levels of anxiety symptoms (89.6%) compared with single women (76.0%). This finding is consistent with previous studies reporting that being divorced or widowed are among significant predictors of anxiety among women.^{22 44}

With regard to education, participants who were educated to at least university level reported the lowest anxiety levels (75.7%) and all the participants who were illiterate or had studied up to secondary school reported anxiety symptoms (100%). This finding is consistent with previous studies reporting that women with lesser education are more likely to develop anxiety.⁵¹ Moreover, in the present study, the following groups reported higher levels of anxiety compared with their counterparts: those who were residents of Kabul (86.6%) in comparison to those who lived in Mazar-e-Sharif (75.4%), those who had jobs (89.5%) in comparison to those who did not have a job (74.8%), those who experienced a bad event in the past month (84.8%) compared with those who did not (74.1%), and those who had been physically ill in the past month (94.4%) compared with those who had not (78.4%).

The findings showed that 86.1% of the participants with very poor QoL also had symptoms of depression. Two-thirds of participants with very poor QoL had symptoms of anxiety ranging from mild to severe levels (63.2%). Collectively, these findings are consistent with previous studies reporting that QoL is lower among individuals with anxiety and depression.²⁶ Mild to severe levels of anxiety were found to be significantly related to all four domains of the QoL (physical domain, psychological domain, social relationship domain, and environment domain). This finding is consistent with the results of a literature review showing that anxiety disorders are associated with global, social, occupational, and physical domains of QoL.⁵² However, according to a study on the mental health of older age groups, anxiety was found to be associated with three domains of QoL (psychological, social, and environmental), but not with the physical domain.⁵³

In the multivariable analysis, the only variables that were significantly associated with depression symptoms were experiencing bad events during the past month, other individuals’ behaviour, QoL psychological domain, QoL social relationship domain, and the presence of anxiety. All other variables such as marital status, physical illness, self-rated QoL, QoL physical domain, and QoL environment domain had no significant contribution in the regression model. Moreover, previous research has shown that depression has a significant impact on all domains of QoL.⁵⁴ The result regarding the marital status is consistent with a cross-sectional study among Saudi medical students reporting there was no association between the student’s marital status and the reported frequency of their depression symptoms.⁵⁵ According to the 2015 national survey (before the return of Taliban), half the women had depression symptoms and more than a half had symptoms related to anxiety. Also, in another study conducted in major provinces of Afghanistan in 2021, almost four-fifths of the participants were found to have depression symptoms,³⁴ which are much lower rates than those in the present study (ie, 9/10 of the total sample reported symptoms of depression or anxiety).⁵⁵

Limitations

The present study has several limitations. There are very few studies that have examined the mental health of Afghan women since the Taliban returned to power in Afghanistan which limits the ability to compare the results here to other studies and find any meaningful trends. Another limitation is that the study did not assess the date of onset of mental health symptoms or poor QoL. Therefore, it is not known whether the participants’ mental health condition changed since the Taliban takeover in Afghanistan or had preceded it. The findings provided estimates of depression and anxiety among Afghan women and the association of these mental health disorders with QoL but all the data were self-report and subject to a range of methods biases. Moreover, the study was cross-sectional, therefore, it was not possible to determine any causality between the variables examined in the present study. Another limitation of the study was that the sample was not representative of all Afghan women. The sample only contained participants from urban areas and the sample had a much greater proportion of educated women than found nationally, and as a consequence a much smaller proportion of illiterate participants than that found nationally. Moreover, it is difficult to determine whether the results are indicative of a snapshot in a particularly fraught time in Afghanistan

The present study’s findings suggest that mental health illnesses can be comorbid with low QoL among Afghan women, and immediate attention is required to address the mental health issues faced by Afghan women under the current Taliban government. Further studies are needed to assess the possibility of gender differences in mental health and QoL by studying cohorts of both men and women under Taliban rule. Moreover, future studies should investigate the potential sources of therapy and their availability to the general population of Afghan women.

Conclusion

The prevalence of depression is high among women living under the government of the Taliban in Afghanistan. Considering the high prevalence of depression, anxiety, their impact on QoL, and the overall quality of healthcare services, international health organisations should implement programs for regular screening of depression and anxiety. Psychological counselling services are needed for vulnerable women living under the government of the Taliban.

Data availability statement

All data relevant to the study are included in the article or uploaded as online supplemental information.

Ethics statements

Patient consent for publication

Not applicable.

Ethics approval

The Afghanistan Centre for Epidemiological Studies—Ethical Committee provided the ethical approval to conduct this study (reference number #45.001; 1 November 2021). During the initial contact with the participants, a description of the study was presented to them. Written or verbal Informed consent was obtained from all the participants in the present study. Participants were informed that they could discontinue with the interview at any point in time from the study.