https://doi.org/10.15218/ejnm.2020.08 Erbil j. nurs. midwifery, Vol. 3, No. (1), May, 2020 Original Article Assessment of the Levels of Hopelessness among the Patients with Major Depressive Disorder in Sulaimani City ABSTRACT INTRODUCTION There is a growing belief that major de- pressive disorder (MDD) can be associated with increased feelings of powerlessness which leads to the cycle of loss. According to the cycle of loss, feelings of powerless- ness leads to feelings of hopelessness, and can lead to a sense of despair which in turn leads into a deeper sense of loss . This cy- cle may continue overtime and perhaps leading to a suicidal behavior [1].Research findings indicated an association between hopelessness with major depressive disor- der [2, 3]. It can be the contributory factors to depression [4, 5]. In the view of Tuck [6] hopelessness is a negative emotion characterized by a lack of hope, optimism and passion. Hopelessness is both a cause and symptom of depression, and in the context of depression, it is a strong predic- tor of suicide according to previous studies [7]. Lubow [8] noted that hopelessness can be a passing part of a depressive episode, or even a brief aspect of grief. Hopeless- ness can be a long term pattern of thinking and feeling, and it is almost inevitably the result of trauma. Living with feelings of hopelessness is very painful experience. Other studies show that hopelessness also leads to low self-esteem [9] and may lead to ineffective problem solving in depressed Background and Objectives: Major depressive disorder associated with greater morbidi- ty and mortality. Many researchers have sought complex association between depres- sions with hopelessness. The level of severity of such factors can play role in the causes, recovery and prediction of depression. The main objective of this study is to assess the levels of hopelessness among patients with major depressive disorder. Methods: A quantitative descriptive study design was conducted at a psychiatric clinic in the Ali Kamal Medical Consultation Center in Sulaimaniya City. A non-probability, conven- ient sampling was recruited of 150 patients with major depressive disorder attending the psychiatric clinic. The data was collected from December, 21st, 2017 to April 1st, 2018 by the researcher of current study through the utilization of structured interview guided by the questionnaire. Result: The results show that the patients with major depressive disorder experience moderate level to severe level of hopelessness. Suicidal attempt is a highly significant fac- tor affecting the levels of hopelessness. Conclusions: The study concluded that hopelessness value on its own the strongest sig- nificant factor may represent emotional source and possibly used to handle or cope with depressed mood by the patients. Keywords: Major Depressive Disorder; Depression; Hopelessness; Patients Taha Ahmad Faraj; Department of Nursing, College of Nursing, University of Sulaimani, Sulaimani, Iraq. )Correspondence: taha.faraj@univsul.edu.iq ) Salwa Shakir Muhsin; Department of Nursing, College of Nursing, University of Sulaimani, Sulaimani , Iraq. 68 Erbil Journal of Nursing & Midwifery Received: 19/8/2019 Accepted: 27/11/2019 Published: 30/5/2020 mailto:Taha.faraj@univsul.edu.iq mailto:Taha.faraj@univsul.edu.iq https://doi.org/10.15218/ejnm.2020.08 Erbil j. nurs. midwifery, Vol. 3, No. (1), May, 2020 Original Article patients with suicidal ideation [10]. Unfor- tunately, hopelessness condition is con- verted into specific symptom pattern of depression, and remains elusive [11]. Huen [12] defined hopelessness as a powerful emotion that often contributes to low mood and may adversely affect the percep- tion of oneself, others, circumstances and even the world. Hopelessness can have a significant influence on human behavior as it may reflect an individual's negative view of the future. Hopelessness in the de- pressed patient is extremely dangerous; not only is the depressed patient express- ing depressed mood and behavior, they also perseverates on the pessimistic view that life is unbearable and positive change is unfathomable. Various studies consist- ently reported that hopelessness is a key variable in linking depression to suicidal behavior [13]. Britton [14] pointed that there is a significant correlation between hopelessness and suicidal ideation com- pared to depression and it is more precise in predicting eventual suicide. A person whose thoughts are hopeless and rigid may conclude that suicide is the only choice. The hopeless person may view death as a means to an end, an opportunity to escape the pain experienced in life. In addition, the impact of hopelessness leads to a lack of adequate coping skills. A person who is experiencing the conceptual feeling of hopelessness tends to think in extremely narrow term. Some patients may deny feel- ing of hopelessness or depression and fo- cus on identification of various somatic complaints as physical symptoms are more socially acceptable than those of psycho- logical nature [15]. A quantitative-descriptive design was used. The study was carried out from December, 10th, 2017 to October, 1st, 2018. Ethical approval for the use of the questionnaire of this study was issued by research ethical committee of the college of Medicine/ University of Sulaimani. Verbal informed consent was taken from patients and rela- tives prior to participation and interview- ing by the researcher for data collection. This study was carried out at a psychiatric clinic in Ali Kamal Medical Consultation Center which is affiliated to the Teaching Hospital in Sulaimani City. A non- probability, convenient sample of 150 pa- tients previously diagnosed with major de- pressive disorder who attended the psychi- atric department were recruited. Criteria for selection included: patients who have a diagnosis of major depressive disorder and are currently non-psychotic as assessed by the consulting psychiatrist; males and fe- males ages 18 years and above and on reg- ular treatment. Patients who have a diag- nosis of major depressive disorder with any co-morbid psychiatric or medical ill- ness were excluded from the study. A questionnaire developed to achieve objec- tives of this study and Beck Hopelessness Scale (BHS) used. This scale includes a list of 20 items with true/false keyed with to- tal score ranging from 0-20 (0-3 minimal hopelessness, 4-8 mild hopelessness, 9-14 moderate hopelessness, and 15-20 severe hopelessness). Statistical package for social science (SPSS) version 22 was used for data analysis. Descriptive statistical data analy- sis was consist of frequencies, percentage, mean, and standard deviation. Inferential statistical data analysis was consist of Cronbach’s Alpha , t-test, and Analysis of variance (ANOVA). Table (1) shows that one-third of the sam- ple (34.0%) are in the age group (28-37) years, and only (4.6%) of them are in age group more than 58 years. The mean of this age group 37.5 ± 11.3. More than half were male (66%) and married (58%). 69 Erbil Journal of Nursing & Midwifery METHODS RESULTS https://doi.org/10.15218/ejnm.2020.08 Erbil j. nurs. midwifery, Vol. 3, No. (1), May, 2020 Original Article from uban area (78%) and only 6% of them were from rural area; In regard to religious status, the table shows that the majority of the participants (74%) engage in religious practice and the least of them (12%) do not engage in any religious practice. Furthermore, 26% completed primary school education, while 20% graduated from a college or institution. Two-thirds (66%) of the study sample are not em- ployed, with barely sufficient economic status 52% and the majority of them were 70 Erbil Journal of Nursing & Midwifery Table 1: Distribution the socio-demographic characteristics of the sample Sociodemographic Characteristics Frequency (Percentage) Age 18-27 year 28-37 year 38-47 year 48-57 year 58 Year or more 31 51 40 21 7 (20.7) (34) (26.7) (14) (4.6) Mean ± SD 37.5 ± 11.03 Gender Male Female 99 51 (66) (34) Marital status Single Married Divorced Widowed 33 87 24 6 (22) (58) (16) (4) Educational level Illiterate Primary school Interme- diate school Secondary school Institute or university 36 39 24 21 30 (24) (26) (16) (14) (20) Occupation Employed Unemployed 51 99 (34) (66) Residential area Urban Sub urban Rural 117 24 9 (78) (16) (6) Economic status Sufficient Somehow sufficient Insufficient 24 78 48 (16) (52) (32) Religious-status practice Partial practice Non practice 111 21 18 (74) (14) (12) Total 150 (100) https://doi.org/10.15218/ejnm.2020.08 Erbil j. nurs. midwifery, Vol. 3, No. (1), May, 2020 Original Article while 32% of them have suicidal attempt and 12% of them attempted more than four attempts, then 8% of them attempted three attempts, also the same percentage (6%) of them attempted one or two attempts. Around two-thirds of the study sample (68%) have no family history of mental illness, while 36% have family his- tory of mental illness among them 24% related second degree of kinship while on- ly 6% related to first and third degrees of kinship. 71 Erbil Journal of Nursing & Midwifery Table (2) shows that more than half of the depressed patients their duration of illness ranged from 1-5 years (58%), and least percentage is from 16-20 years (4%). The majority of the study sample (74%) have no admission to mental hospital, only 10% of them have admitted once and 4% have their three times of hospitalizations and the same percentage (4%) have more than four times of hospitalizations. Two third of the sample (68%) have no suicidal attempt Table 2 :Distribution of the sample according to their psychiatric history characteristics Psychiatric history Clinical characteristics Frequency (Percentage) Duration of illness 1-5 years 6-10 years 11-15 years 16-20 years 21-25 years 87 36 12 6 9 (58) (24) (8) (4) (6) Number of hospitalization Non 1 time 2 times 3 times 4 times and more 111 15 12 6 6 (74) (10) (8) (4) (4) Suicidal attempt No Yes 102 48 (68) (32) Number of Suicidal attempt No attempt 1 attempt 2 attempt 3 attempt 4 attempt and more 102 9 9 12 18 (68) (6) (6) (8) (12) Family history of mental illness No Yes 96 54 (64) (36) Family member with illness Non First degree Second degree Third degree 96 9 36 9 (64) (6) (24) (6) Total 150 (100) https://doi.org/10.15218/ejnm.2020.08 Erbil j. nurs. midwifery, Vol. 3, No. (1), May, 2020 Original Article 72 Erbil Journal of Nursing & Midwifery Table(3)shows statistically non-significant difference between calculated mean ( =9.860) and theoretical mean (×=10) (- test =0.367 SD ± 4.676) at ≤ 0.05 level. The results indicate that the level of hopeless- ness in general, was moderate among the patients with major depressive disorder. Table (4) shows that the distribution of the patients according to the hopelessness scale index. The table shows that 40% of the total patients were having moderate level of hopelessness and the mean score ranged from 9-14, followed by 30% who experienced mild levels of hopelessness and the mean score ranged from 4-8, then 18% who experienced levels of severe hopelessness and the mean score ≥ 15, and 12% of the total sample were experi- encing minimal level of hopelessness and the mean score ranged from 0-3.Table (5) shows that there was statistically highly significant mean score of hopelessness (- test =9.1204 at <0.001) in regard to pa- tients attempted suicide. Table 3 :the significant difference between calculated mean and theoretical mean in hopelessness measures for the sample using -test Variable Sample Calculative mean standard deviation theoretical mean value Level of signifi- cance hopelessness 150 9.860 4.676 10 0.367 Non-significant Table 4 :Distribution of the sample according to the level of hopelessness Statistical Indicator Level of hopelessness Total Minimal Score 0-3 Mild Score 4-8 Moderate Score 9-14 Sever Score ≥15 Frequency 18 45 60 27 150 Percentage %12 %30 %40 %18 %100 Table 5 :the differences of mean scores of hopelessness in regard to suicide attempt fac- tor among patients Variables Suicide attempt Number Mean score Standard Deviation value Level of sig- nificant Hopelessness No 102 8.41 3.96 9.1204 0.001 Yes 48 12.93 4.60 * SEM = (0.3233 and 0.3756), df = 298 https://doi.org/10.15218/ejnm.2020.08 Erbil j. nurs. midwifery, Vol. 3, No. (1), May, 2020 Original Article 73 Erbil Journal of Nursing & Midwifery The findings showed that both the ob- served mean score 9.860 4.676 and theo- retical mean score 10.0 4.676 have statis- tically non-significant differences (p>0.05) which means that high distribution of the study sample experiences moderate level of hopelessness (40%). Findings are con- sistent with results of Ribeiro[16] study in USA and Vass [17] study in UK. Hopeless- ness is the subjective appraisal of negative expectations about the occurrence of high- ly valued outcomes coupled with the sense that one lacks control over desired to event in the future [18].Hopelessness has been related to the onset or development of depression [19]. In a systematic review study by Soundy [20], hopelessness was identified as a major barrier to recovery from depression. A recent study noted that hopelessness is a powerful emotion that often contributes to low mood and can play a mediating role to effects symp- toms and subjective recovery [12].Although, the results of this study re- vealed a moderate (40%) to severe (18%) level of hopelessness among study pa- tients, the mechanism of how hopeless- ness influences depression is not an objec- tive of this study. However Fortinash and Worret [11] stated that unfortunately the specific mechanisms of hopelessness is converted into the specific symptom pattern of depression and hopelessness condition remains elusive. It is evident based on the results of present study that patients with major depressive disorder clearly experience a condition of hopeless- ness. In this study, suicidal attempts is a significant factor effecting hopelessness level (p <0.001). These results are con- sistent with the study by Pomplim [19], Kaviani [1] and Ribeiro [16] which deter- mined that hopelessness has been related to the onset or development of depression and is associated with suicidal ideation. It is also recognized as better predictor for suicidal intent than depression. These re- sults are also in line with studies by Fortinash and Worret [11] which reported that suicide behaviors are symptoms of depressive episodes, other symptoms of depression relating to apathy, lack of mo- tivation, and sadness. These symptoms as well as other symptoms of depression are all believed to flow from the condition of hopelessness. Most of patients in this study were males with a mean age of 37.5 years, unem- ployed, living in urban areas, practicing religious activities and they were less like- ly to be admitted to hospital although du- ration of illness ranged from 1-25 years. The patients experience moderate level of hopelessness. Suicidal attempt is a highly significant factor affecting the levels of hopelessness. Importance of assessing hopelessness in patients with major depressive disorder and provide critical evidence of the need for nurses and clinicians to encourage pa- tients to participate in social and recrea- tional outpatient activities. The author report no conflict of interest. [1] Kaviani H, Rahimi M, Rahimi-Darabad P, Naghavi HR. Overgeneral Memory Retrieval and Ineffective Problem-Solving in De- pressed Patients with Suicidal Ideation: Im- plications for Therapy. 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