Prevalence of depression among adult psoriatic patients in Palestine: a cross-sectional study in primary healthcare settings

Abstract

Background

Psoriasis is a chronic inflammatory skin disease associated with substantial psychosocial burden and an elevated risk of depression.

Objectives

This study aimed to estimate the prevalence of depression among adult psoriasis patients and to identify associated demographic, clinical and psychosocial factors.

Methods

A cross-sectional study was conducted between March and September 2025 across governmental dermatology clinics in the West Bank. A total of 320 adult patients with psoriasis completed interviewer-assisted Arabic questionnaires with a response rate of 92.5%. Depression was assessed using the validated Patient Health Questionnaire-9 (score ≥10 indicating depression). Psoriasis severity and psychosocial impact were evaluated using the self-administered Simplified Psoriasis Index. Multivariate logistic regression was used to identify independent predictors of depression.

Results

The prevalence of depression was 33.1% based on a screening tool (95% CI 28.0% to 38.6%). In multivariate analysis, lower educational attainment (elementary/middle school vs university: adjusted OR (aOR)=2.6; 95% CI 1.3 to 5.4; p=0.013) and higher psychosocial impact score (aOR=1.3; 95% CI 1.1 to 1.4; p<0.001) were independently associated with depression. Female sex demonstrated a borderline, non-significant association with depression (aOR=1.7; p=0.064). Notably, clinical severity of psoriasis was not a significant predictor after adjustment, although 50% of patients with severe disease screened positive for depression. Pruritus was prevalent (79.7%) and significantly associated with depression in univariate analysis.

Conclusions

Depression affects approximately one in three patients with psoriasis in this primary care setting, associated more closely with psychosocial burden and socioeconomic factors than with clinical disease severity. These findings underscore the critical need for routine depressive symptom screening and integrated mental health support within dermatological care, particularly in conflict-affected and resource-limited regions.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• The study used a large sample size with a notably high response rate of 92.5% within a primary healthcare setting.

• Data collection relied on well-validated screening instruments to assess both psoriasis severity and its psychosocial impacts.

• The cross-sectional design limits the ability to establish definitive causal relationships between psoriasis and depression.

• Depression and psoriasis severity were assessed using self-reported screening tools rather than formal clinical diagnostic interviews or objective clinician-led evaluations.

• The timing of data collection during the Gaza War represents a unique environmental and psychological context that may influence the generalisability and precision of the findings.

Introduction

Psoriasis is a chronic, multifactorial, inflammatory, immune-mediated skin disease characterised by well-defined red, scaly plaques.¹ A systematic review of the global epidemiology of psoriasis reveals that its prevalence among adults ranges from 0.51% to 11.43%.² There is a confirmed association between psoriasis and various diseases related to metabolic syndrome, including arterial hypertension, hyperlipidaemia and diabetes.³ This relationship also extends to systemic chronic inflammatory diseases.

Psoriasis has a significant psychosocial burden, which may be exacerbated by the stigma that patients experience because of the way their skin looks. Several studies revealed that patients with psoriasis had a higher prevalence of depression than those without psoriasis.^{4 5} When comparing psoriasis patients to non-psoriasis controls, the pooled relative risk of depression was 1.48.⁶ Additionally, there is currently increasing evidence of a bidirectional relationship between depression and psoriasis caused by shared biological processes.⁷

Studies have also shown a correlation between reduced quality of life, depression, anxiety and psoriasis severity, as measured by reliable clinical tools, such as the Psoriasis Area and Severity Index (PASI) and body surface area of psoriasis.^{8 9} Patients demonstrated marked improvements in work and leisure activities as the level of skin clearance improved.¹⁰ Thus, it is important to understand how patients view their disease and its impact on their daily lives.

Risk factors for depression in psoriasis patients include age of 20 to 50, female sex, lower socioeconomic status, a long period of illness, a low quality of life, the presence of pruritus, the location of psoriasis lesions and concurrent medical conditions.^{11 12} Also, patients with severe psoriasis, psoriatic arthritis or a history of depression are more likely to screen positive for major depressive disorder.¹³ A systematic review and meta-analysis concluded the prevalence of depression in patients with psoriatic arthritis is 1.68 times higher compared with those without psoriatic arthritis.¹⁴

It is also worth noting that in patients with psoriasis, an improper early diagnosis of depression may impact the evaluation and management of this severe disease, which increases the risk of suicide if left untreated or treated inappropriately.¹⁵ According to WHO guidelines, patients with psoriasis and its comorbidities should receive comprehensive, individually tailored treatment that considers their needs and is coordinated by multidisciplinary teams of specialists, including mental health professionals.

In Palestine, screening for depression is not part of the standard evaluation for psoriatic patients. This study aims to estimate the prevalence of depression and determine its associated demographic and clinical features among this population in primary healthcare (PHC) settings. We will also evaluate psoriasis severity and its psychosocial impact, and correlate these factors with depression. We anticipate that our findings will provide the first comprehensive data on this comorbidity in the region and highlight the critical need for integrated dermatological and psychiatric care.

Methodology

Study design and population

This cross-sectional study was conducted between 1 March 2025 and 1 September 2025, across dermatology clinics located within Governmental PHC centres in the West Bank, Palestine. Each district health directorate operates a specialised dermatology clinic that provides comprehensive care for patients with psoriasis. As these public PHC centres are the sole facilities authorised to dispense all categories of government-subsidised psoriasis medications, they provide access to a diverse and representative population of patients receiving routine psoriasis care within the public healthcare system. This manuscript was prepared in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies.¹⁶ The STROBE checklist was used to guide the reporting and editing of the manuscript and is provided as online supplemental file 1).

Eligible participants were adults (≥18 years) with a clinical diagnosis of psoriasis confirmed by a dermatologist for at least 1 month. Exclusion criteria included patients younger than 18 years, individuals with dermatological conditions other than psoriasis, and those with mental or neurological disorders. Patients who declined to participate were also excluded.

Sampling technique and size

The sample size was estimated using the OpenEpi sample size⁴ calculator. Based on the Palestinian Annual Health Report 2024, the mid-year population of the West Bank was approximately 3 million, and the regional prevalence of psoriasis was estimated at 4.6%.¹⁷ This equates to an estimated target population of 1 38 000 patients with psoriasis. Assuming a 95% confidence level, a 5% margin of error, and an expected prevalence of 25%, based on the average prevalence reported in previous studies,^{4 5 11 13 18 19} the minimum required sample size was estimated at 288 participants.

We randomly selected seven dermatology clinics from the 13 available in the West Bank. We used systematic random sampling, inviting every third patient with psoriasis presenting to the clinic on a given day to participate.

Data collection and measurement tools

Data were collected through interviewer-assisted, structured questionnaires (online supplemental file 2) administered in Arabic in private rooms within the dermatology clinics to ensure confidentiality and patient comfort. Trained interviewers administered the questionnaire, which consisted of three sections. The first section gathered sociodemographic and clinical information, including sex, age, place of residence, educational level, income, employment status, marital status, smoking status, comorbidities, family history of psoriasis, age at first diagnosis, presence of pruritus, psoriatic arthritis, nail involvement and recent use of antidepressants.

The second section assessed psoriasis severity, psychosocial impact and treatment history using the validated Arabic version of the Self-Assessment Simplified Psoriasis Index (sa-SPI).²⁰ The sa-SPI comprises three components: disease severity (sa-SPI-s), psychosocial impact (sa-SPI-p) and previous history and interventions (sa-SPI-i). For severity, patients rated psoriasis across ten body areas and overall plaque severity, generating a composite score (0–50) categorised as mild (<10), moderate (10–20) or severe (>20). The psychosocial component measured the impact of psoriasis on daily life using a 0–10 scale, while the history component documented disease course and prior treatments including biologics, methotrexate, acitretin, ciclosporin, phototherapy and topical therapies.^{21 22}

The third component used the validated Arabic version of the Patient Health Questionnaire-9 (PHQ-9) to screen for depression.²³ The PHQ-9 assesses the frequency of nine Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) depressive symptoms over the past 2 weeks, with each item scored from 0 (‘not at all’) to 3 (‘nearly every day’), resulting in a total score ranging from 0 to 27. A cut-off of ≥10 was applied to classify participants as depressed, consistent with established evidence showing 85% sensitivity and specificity for major depressive disorder.²⁴

To ensure the validity and reliability of the data collection process, three experts in the field reviewed the measurement tool for content accuracy and clarity. Additionally, we conducted a pilot study with 20 patients to test the questionnaire’s feasibility and identify potential ambiguities. Furthermore, all data collectors underwent rigorous training on standardised data collection techniques to minimise interviewer bias and ensure consistency across all patient assessments.

Data analysis

Data were analysed using IBM SPSS Statistics software (V.27). Continuous variables were summarised using means and SD, while categorical variables were described as frequencies and percentages. Prior to analysis, the dataset was screened for missing values. Cases with missing data on variables required for a specific analysis were handled using listwise deletion, and analyses were performed on complete cases only. Bivariate analyses were conducted to assess associations between variables: Pearson’s χ² test was used for relationships between two categorical variables, and the independent samples t-test was employed to compare means of a continuous variable across two categories of a categorical variable. To identify factors independently associated with depressive symptoms, a multivariable logistic regression analysis was performed. Candidate variables were selected for the final model using a combined strategy: this included all covariates demonstrating a significance level of p<0.10 in the bivariate analysis, alongside established risk factors and confounders identified as clinically or theoretically relevant in previous literature. Prior to performing the multivariable logistic regression, multicollinearity among the predictor variables was assessed using the variance inflation factor (VIF), with a VIF <5 indicating an acceptable lack of collinearity. Statistical significance was defined as a two-tailed p<0.05.

Patient and public involvement

This research was done without patient or public involvement. Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.

Results

Of the 345 psoriatic patients invited to participate in the study, 320 provided consent, resulting in a response rate of 92.5%. The sample was evenly distributed by sex (50.0% males and 50.0% females). The mean age of the participants was 45.0±14.5 years, with the majority (60.3%) being over 40 years old. Slightly more than half (51.2%) resided in rural areas and 63.7% were not currently employed. Over half (54.4%) reported a monthly household income of less than 2000 NIS. Most participants were married (79.7%), and 35.9% were current smokers. Comorbid chronic conditions were present in 42.2% of the cohort, most commonly hypertension (20.6%) and type 2 diabetes mellitus (19.1%) (table 1).

Table 1. Demographic characteristics of the studied psoriatic patients (n=320).

Variable	Frequency (%)	Mean±SD
Sex
Male	160 (50.0)
Female	160 (50.0)
Age groups (years)		45.0±14.5
18–30	63 (19.7)
31–40	64 (20.0)
>40	193 (60.3)
Residency
Urban	154 (48.1)
Rural	164 (51.2)
Missing	2
Educational level
Elementary or middle school	116 (36.3)
Secondary school	104 (32.5)
University	100 (31.3)
Working status
Working	116 (36.3)
Not working	204 (63.7)
Monthly income level
<2000	174 (54.4)
2000–3500	71 (22.2)
>3500	75 (23.4)
Marital status
Married	255 (79.7)
Unmarried	65 (20.3)
Smoking status
Smoker	115 (35.9)
Non-smoker	205 (64.1)
Presence of chronic diseases (yes)	135 (42.2)
Type of chronic disease
Type 2 diabetes mellitus	61 (19.1)
Hypertension	66 (20.6)
Ischaemic heart disease	32 (10.0)
Chronic kidney disease	3 (0.9)
Pulmonary disease	9 (2.8)
Neoplasm	7 (2.2)

Clinically, 64.4% of patients had lived with psoriasis for more than 10 years, and 38.8% reported either disease onset before the age of 10 or a disease duration exceeding 20 years. A positive family history of psoriasis was reported by 44.4% of participants. Psoriatic arthritis and nail involvement were present in 35.6% and 34.1% of patients, respectively. The majority (79.7%) experienced pruritus, while only 5.3% reported recent use of antidepressants. The mean psychosocial impact score was 5.8±3.2 (table 2).

Table 2. Clinical characteristics of the studied psoriatic patients.

Variable	Frequency (%)	Mean±SD
Family history of psoriasis	142 (44.4)
Age when first diagnosed with psoriasis
<10 years of age	43 (13.4)
10–20 years of age	86 (26.9)
>20 years of age	191 (59.7)
Presence of pruritus	255 (79.7)
Presence of psoriatic arthritis	114 (35.6)
Presence of nail psoriasis	109 (34.1)
Recent use of antidepressants	17 (5.3)
Psychosocial impact		5.8±3.2

Regarding the disease history and therapeutic interventions, nearly all patients (98.8%) had used topical therapies. Systemic treatments included methotrexate (36.3%), acitretin (30.0%) and biologics (38.8%). Phototherapy Ultraviolet B/ Psoralen and Ultraviolet A (UVB/PUVA) and cyclosporine were less frequently used (15.9% and 3.8%, respectively). A history of severe psoriasis phenotypes, erythrodermic or generalised pustular psoriasis, was reported by 21.3% of patients, though only 3.8% had required hospitalisation (table 3).

Table 3. Distribution of self-assessed patients’ disease history and therapeutic interventions.

Disease history and interventions	N (%)
Had psoriasis for >10 years	206 (64.4%)
Had psoriasis for >20 years or before the age of 10	124 (38.8)
Had had erythrodermic or generalised pustular psoriasis	68 (21.3)
Hospitalised because of psoriasis	12 (3.8%)
Received at least one course of UVB treatment or PUVA	51 (15.9)
Received methotrexate	116 (36.3%)
Received acitretin	96 (30.0%)
Received ciclosporin	12 (3.8%)
Received biologic therapy	124 (38.8%)
Received another agent (topical)	316 (98.8)

PUVA, Psoralen plus Ultraviolet A; UVB, Ultraviolet B.

Disease severity varied across body regions. The scalp/hairline, knees/lower legs/ankles and hands/fingers/fingernails were among the most commonly and severely affected areas. On the plaque severity scale, 42.2% of patients exhibited definite redness, scaling or thickness (score=2), while only 1.6% showed clear or minimal signs of disease (score=0 or 1) (figure 1). Overall, disease severity was classified as mild in 61.2%, moderate in 32.5% and severe in 6.3% of patients.

Figure 1. Patient-reported psoriasis distribution across body areas (A) and plaque severity (B) using the self-assessed Simplified Psoriasis Index.

A total of 106 patients screened positive for depressive symptoms, corresponding to a prevalence of 33.1% (95% CI 28.0% to 38.6%) in the study population. In univariate analysis, depression was significantly more prevalent among females (40.0% vs 26.3%; p=0.009), individuals with lower educational attainment (44.0% among those with elementary or middle school education vs 23.0% among university graduates; p=0.004), and those reporting pruritus (36.9% vs 18.5%; p=0.005). Although not statistically significant (p=0.086), a trend towards higher depression prevalence was observed with increasing psoriasis severity: 29.1% in mild, 37.5% in moderate and 50.0% in severe disease. Depressed patients also reported significantly higher psychosocial impact scores (7.3±2.8) compared with non-depressed patients (5.0±3.2; p<0.001) (table 4).

Table 4. Univariate and multivariate analysis of psoriasis patients’ depression status with their demographic and clinical characteristics.

Variable	Depression		P value	Multivariate analysis
	Yes	No		aP value	aOR (95% CI)
Sex
Male*	42 (26.3%)	118 (73.8%)	0.009	0.064	1.7 (.97 to 2.9)
Female	64 (40.0%)	96 (60.0%)
Age groups (year)
18–30	27 (42.9%)	36 (57.1%)	0.099	0.106	2.0 (0.92 to 4.6)
31–40	16 (25.0%)	48 (75.0%)		0.359	0.71 (0.34 to 1.5)
>40*	63 (32.6%)	130 (67.4%)			1
Residency
Urban	47 (30.5%)	107 (69.5%)	0.302	--	--
Rural	59 (36.0%)	105 (64.0%)
Educational level
Elementary or middle school	51 (44.0%)	65 (56.0%)	0.004	0.013	2.6 (1.3 to 5.4)
Secondary school	32 (30.8%)	72 (69.2%)		0.052	1.9 (0.99 to 3.5)
University*	23 (23.0%)	77 (77.0%)
Working status
Working	39 (33.6%)	77 (66.4%)	0.887	--	--
Not working	67 (32.8%)	137 (67.2%)
Monthly income level (NIS)
<2000*	64 (36.8%)	110 (63.2%)	0.087		1
2000–3500	25 (35.2%)	46 (64.8%)		0.689	0.87 (0.45 to 1.7)
>3500	17 (22.7%)	58 (77.3%)		0.645	0.84 (0.39 to 1.8)
Marital status
Married	83 (32.5%)	172 (67.5%)	0.665	--	--
Unmarried	23 (35.4%)	42 (64.6%)
Smoking status
Smoker	36 (31.3%)	79 (68.7%)	0.604	--	--
Non-smoker	70 (34.1%)	135 (65.9%)
Chronic disease
Yes	43 (31.9%)	92 (68.1%)	0.679	0.2136	1.5 (0.82 to 2.6)
No	63 (34.1%)	122 (65.9%)			1
Family history of psoriasis
Yes	46 (32.4%)	96 (67.6%)	0.804	--	--
No	60 (33.7%)	118 (66.3%)
Psoriasis onset
Before the age of 10	14 (32.6%)	29 (67.4%)	0.795
Between the age of 10 and 20	31 (36.0%)	55 (64.0%)		--	--
After the age of >20	61 (31.9%)	130 (68.1%)
Pruritus
Yes*	94 (36.9%)	161 (63.1%)	0.005	0.177	1.7 (0.79 to 3.6)
No	12 (18.5%)	53 (81.5)
Psoriatic arthritis
Yes*	43 (37.7%)	71 (62.3%)	0.194	0.349	1.3 (0.73 to 2.4)
No	63 (30.6%)	143 (69.4%)			1
Nail psoriasis
Yes*	41 (37.6%)	68 (62.4%)	0.220	0.345	1.4 (0.72 to 2.5)
No	65 (30.8%)	146 (69.2%)			1
Psoriasis severity
Mild*	57 (29.1%)	139 (70.9%)	0.086		1
Moderate	39 (37.5%)	65 (62.5%)		0.85	1.1 (0.38 to 3.4)
Severe	10 (50.0%)	10 (50.0%)		0.70	1.3 (0.40 to 3.8)
Psoriasis psychological impact (mean±SD)	7.3±2.8	5.0±3.2	<0.001	<0.001	1.3 (1.1 to 1.4)
Psoriasis interventions and prior history (mean±SD)	3.5±1.7	3.5±1.9	0.866	0.166	1.1 (.95 to 1.3)

^*Reference group.

aOR, adjusted OR; aP value, adjusted p value.

Multivariate logistic regression analysis identified two independent predictors of depression. Patients with elementary or middle school education had 2.6 times higher odds of depression compared with those with university-level education (aOR=2.6; 95% CI 1.3 to 5.4; p=0.013). Additionally, each one-unit increase in the psychosocial impact score was associated with a 30% increase in the odds of depression (aOR=1.3; 95% CI 1.1 to 1.4; p<0.001). Female sex demonstrated a borderline, non-significant association with increased odds of depression (aOR=1.7; 95% CI 0.97 to 2.9; p=0.064), falling just outside the threshold for conventional statistical significance (table 4).

Discussion

This study provides a comprehensive assessment of depression prevalence and its associated demographic, clinical and psychosocial correlates among psoriasis patients attending PHC centres in Palestine. We found that 33.1% of patients screened positive for depressive symptoms, a figure substantially higher than the estimated global prevalence of depression in the general population (approximately 5%–10%)²⁵ and consistent with but at the higher end of rates reported in other psoriasis cohorts worldwide (10%–40%).^{4 5 11 13 18 19} Differences may stem from variations in assessment tools, population characteristics and the context of ongoing conflict in Gaza during data collection, which likely intensified psychological distress and worsened socioeconomic conditions. These findings highlight the significant mental health burden of psoriasis, particularly in resource-limited settings with limited access to integrated dermatological and psychiatric care.

A key finding of our study is the strong independent association between lower educational attainment and depression. Patients with only elementary or middle school education had 2.6 times higher odds of depression compared with those with university-level education, even after adjusting for other covariates. This aligns with recent evidence, which has identified low socioeconomic status and limited education as consistent risk factors for psychological morbidity in chronic skin diseases.^{4 11 19} Education may serve as a proxy for health literacy, coping resources and access to social support, factors that buffer against the emotional toll of visible, stigmatising conditions like psoriasis. In the Palestinian context, where structural barriers to education and employment persist, this finding highlights the need for targeted psychosocial support for vulnerable subgroups.

Another important finding is the association between psychosocial impact and depression, with each one-point increase in the psychosocial impact score corresponding to a 30% increase in the odds of depression, consistent with results from other studies.⁵ This finding aligns with a growing body of evidence indicating that the psychological burden of psoriasis is linked less to clinical disease severity and more to subjective experiences of stigma, social withdrawal and impaired quality of life.²⁶

In terms of severity, most patients in our cohort fell into the mild-to-moderate categories, with 6.3% reporting severe disease, findings consistent with prior studies employing the same instrument.^{5 21 22 27} While this distribution may appear reassuring, it is important to note that even patients with mild clinical disease reported significant psychosocial impact. Although a higher proportion of patients with severe psoriasis screened positive for depressive symptoms (50%) compared with those with mild disease (29%), this association did not achieve statistical significance in multivariate analysis (p=0.086). This contrasts with some earlier reports linking greater clinical severity to increased depression risk,⁵ yet aligns with a growing body of evidence suggesting that objective measures of skin involvement are often insufficient to predict psychological outcomes.²⁸ Our results reinforce a paradigm shift towards patient-centred care, suggesting that the mental health burden in psoriasis may be associated less with clinical disease severity and more closely linked to subjective psychosocial factors, such as stigma and appearance-related distress.²⁹ This underscores the critical need in PHC settings to go beyond clinical severity and implement routine psychosocial screening to ensure a more holistic and effective approach to management.

The high prevalence of pruritus (79.7%) and its significant univariate association with depression further reinforce the multifactorial nature of psychological distress in psoriasis. Although this association weakened after adjustment in multivariable analysis, pruritus is frequently cited as one of the most depressive symptoms, associated with sleep disturbance, anxiety and reduced quality of life.^{19 30} Our findings echo recent data from Arab countries that symptom burden in psoriatic patients, not just plaque visibility, contributes meaningfully to depression in psoriasis populations.^{31 32} This suggests that symptom control, particularly of pruritus, should be a therapeutic priority alongside skin clearance.

Nail involvement and psoriatic arthritis were reported in one-third of patients, consistent with prevalence estimates reported in prior studies.^{14 33} These manifestations are of particular concern given their association with greater disease burden, functional impairment and lower quality of life. However, in contrast to previous studies,^{13 14} the presence of psoriatic arthritis, nail psoriasis and the duration of psoriasis did not show a significant correlation with depression. This may reflect contextual differences in our population, such as the overwhelming influence of sociopolitical stressors in the occupied Palestinian territory, which were not measured and may confound the results, overshadowing the contribution of clinical disease features to depressive symptoms.

Interestingly, female sex was significantly associated with depression in univariate analysis but lost significance in the multivariate model, though it approached conventional thresholds (aOR=1.7, p=0.064). This partial attenuation may reflect the mediating role of psychosocial factors or education, which are often gendered in conservative societies. While global literature consistently reports higher depression rates among women with psoriasis,^{11 12 28} cultural norms in Palestine may differentially shape help-seeking behaviours, symptom reporting or social roles, warranting further qualitative exploration.²⁶

The main strengths of this study are its large sample size and the use of validated instruments to assess both psoriasis severity and psychosocial impact. Additionally, the high response rate (92.5%) further supports the representativeness of the findings. Nonetheless, several limitations should be noted. First, the cross-sectional design precludes causal inference between psoriasis-related factors and depression. Second, depression was assessed through a screening tool rather than clinical diagnostic interviews, which may have led to misclassification. Third, unmeasured variables such as social support, coping styles, trauma, economic challenges and access to healthcare services were not captured but may have influenced the observed associations. Fifth, psoriasis severity was evaluated subjectively via the sa-SPI instead of the objective PASI, which may raise informational bias.

Conclusions

In conclusion, psoriasis in our cohort was characterised by chronicity, frequent comorbidities and significant psychosocial impact, even among patients with mild-to-moderate disease severity. Depression affects approximately one in three individuals with psoriasis in our study, with psychosocial burden and lower educational attainment identified as significant independent risk factors. These results underscore the importance of a holistic approach to psoriasis management, one that extends beyond skin-directed therapy to actively support mental health and social well-being. In the context of Palestine, where ongoing occupation and systemic constraints limit access to comprehensive healthcare, routine screening for depression in PHC settings is especially critical.

Data availability statement

Data are available on reasonable request.