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Aims: The present survey aims to assess the overall mood disorder prevalence and identify associated socio-demographic and clinical factors in a Tunisian community sample, with special attention to the COVID-19 pandemic. Background: Mood disorders are one of the leading causes of all non-fatal burden of disease, with depression being at the top of the list. The COVID-19 pandemic may have increased the prevalence of mood disorders, especially in Low and Middle income countries (LMICs) and in vulnerable populations. Objectives: 1. Assess point and lifetime prevalence of depressive and bipolar disorders as well as subthreshold bipolarity in a representative population sample of La Manouba governorate and assess treatment patterns for these disorders. 2. Study socio-demographic and clinical correlates of mood disorders 3. Assess the association between mood disorders and quality of life 4. Study the impact of the COVID-pandemic on the prevalence of mood disorders 5. Assess coping mechanisms to the COVID-pandemic and whether these mechanisms moderate the appearance of mood disorders or symptoms since the beginning of the pandemic Method: This is a household cross-sectional observational survey to be conducted in La Manouba Governorate in a sample of 4540 randomly selected individuals aged ≥ 15 years. Data collection will be carried out by trained interviewers with clinical experience, through face-to-face interviews and the use of the computer assisted personal interviewing approach (CAPI). The following assessment tools are administered: Result: Structured clinical Interview for DSM IV-TR (Mood disorder section and Screening questions on Anxiety), Mood Disorder Questionnaire (MDQ), Suicide Behaviors Questionnaire-Revised (SBQ), 12-item Short Form Survey (SF-12), the Brief-COPE, and a questionnaire about headache. In addition, socio-demographic and clinical data will be collected. Conclusion: This will be one of the very few household surveys in a general population sample to assess mental health problems and COVID-19 related variables since the beginning of the pandemic. Through this research, we aim to obtain an epidemiological profile of mood disorders in Tunisia, and an estimation of the impact of the COVID-19 pandemic on their prevalence. Results should contribute to improving mental health care in Tunisia.

OBJECTIVE: Circadian rhythm disruption is commonly observed in bipolar disorder (BD). Daylight is the most powerful signal to entrain the human circadian clock system. This exploratory study investigated if solar insolation at the onset location was associated with the polarity of the first episode of BD I. Solar insolation is the amount of electromagnetic energy from the Sun striking a surface area of the Earth.METHODS: Data from 7488 patients with BD I were collected at 75 sites in 42 countries. The first episode occurred at 591 onset locations in 67 countries at a wide range of latitudes in both hemispheres. Solar insolation values were obtained for every onset location, and the ratio of the minimum mean monthly insolation to the maximum mean monthly insolation was calculated. This ratio is largest near the equator (with little change in solar insolation over the year), and smallest near the poles (where winter insolation is very small compared to summer insolation). This ratio also applies to tropical locations which may have a cloudy wet and clear dry season, rather than winter and summer.RESULTS: The larger the change in solar insolation throughout the year (smaller the ratio between the minimum monthly and maximum monthly values), the greater the likelihood the first episode polarity was depression. Other associated variables were being female and increasing percentage of gross domestic product spent on country health expenditures. (All coefficients: P ≤ 0.001).CONCLUSION: Increased awareness and research into circadian dysfunction throughout the course of BD is warranted.

Background Studies about the two most used and validated instruments for the early detection of Bipolar Disorder (BD), the 32 - item Hypomania Checklist (HCL - 32) and the Mood Disorder Questionnaire (MDQ), are scarce in non-Western countries. This study aimed to explore the reliability, factor structure, and criterion validity of their Arabic versions in a sample of Tunisian patients diagnosed with mood disorders. Methods The sample included 59 patients with BD, 86 with unipolar Major Depressive Disorder (MDD) and 281 controls. Confirmatory factor analysis was applied to show that a single global score was an appropriate summary measure of the screeners in the sample. Receiver Operating Characteristic analysis was used to assess the capacity of the translated screeners to distinguish patients with BD from those with MDD and controls. Results Reliability was good for both tools in all samples. The bifactor implementation of the most reported two-factor model had the best fit for both screeners. Both were able to distinguish patients diagnosed with BD from putatively healthy controls, and equally able to distinguish patients diagnosed with BD from patients with MDD. Conclusion Both screeners work best in excluding the presence of BD in patients with MDD, which is an advantage in deciding whether or not to prescribe an antidepressant.

The coronavirus disease 2019 (COVID-19) pandemic created a situation of general distress. Although the focus has been initially more on the physical health during the pandemic, mental health concerns linked to the lockdown have quickly risen. This study aims to assess the effect of the COVID-19-related lockdown on Tunisian women's mental health and gender-based violence. An online survey was conducted, using the Depression Anxiety and Stress Scales (DASS-21) and the Facebook Bergen Addiction Scale (FBAS). We chose a female-exclusive social group on Facebook and used the snowball sampling method. A total of 751 participants originating from all the Tunisian regions completed the questionnaire. More than half of the participants (57.3%) reported extremely severe distress symptoms, as per the DASS-21. Those who had a history of mental illness and who were allegedly abused during lockdown were found to have more severe symptoms of depression, anxiety, and stress. Around 40% of women reported problematic social media use. Violence against women also reportedly increased significantly during the lockdown (from 4.4 to 14.8%; p < 0.001). Psychological abuse was the most frequent type of violence (96%). Women who had experienced abuse before the lockdown were at an increased risk of violence during lockdown (p < 0.001; OR = 19.34 [8.71-43.00]). To our knowledge, this is the first study that evaluates the acute impact of COVID-19 on mental health and violence against women in Tunisia, Africa, and the Arab world. It may be a sound basis for developing a more effective psychological intervention aimed at women in these regions.

Introduction: Treatment resistant schizophrenia (TRS), affecting approximately one-third of patients with schizophrenia, is associated with a serious impairment in global psychosocial functioning. Clozapine is the only licensed drug for TRS. However its prescription remains limited by its side effects requiring mandatory monitoring. The need to identify clinical factors associated with good response to clozapine in TRS has been established. The presence of ethnic differences in these factors and the scarcity of data on the Tunisian or more generally the North-African population warrants the conduct of a clinical study on the subject. The aim of this study was to investigate demographic, clinical, and biochemical patient characteristics as potential predictors of response to clozapine. Methods: This is a cross-sectional and retrospective study, at the “F and A psychiatry departments” of Razi Hospital in Manouba, Tunisia. All patients, with DSM 5 diagnosis of schizophrenia in its resistant form, on clozapine for at least 12 months and who consulted from June 1, 2018 to November 30, 2018 were included. We investigated premorbid functioning by the premorbid adjusment scale, demographic and clinical characteristics, and clozapine plasma level as potential clozapine response predictors. The response to clozapine was defined by a total BPRS score of 35 or less. Results: Sixty-three patients were included in the study. The mean age at clozapine introduction was 30,84 ±9,25 years. The mean duration of clozapine treatment was 7,22 ± 4,02 years.There were 16 clozapine responders (25%) who had BPRS total scores below or equal to 35 and 47 non-responders (75%).A higher premorbid social functioning in childhood (p = 0,018) and early adolescence (p = 0,024) was associated with better response to clozapine. A delay clozapine initiation shorter than 7 years(p = 0,036), one atypical antipsychotic trial (p = 0,029) and schizophrenia paranoid subtype (p

Background Vaginismus affects up to 1% of the female population and often represents a physical manifestation of an underlying psychological problem. Our objective was to investigate the psychosomatic impact of vaginismus in pregnant women and evaluate the quality of their therapeutic care in Tunisia. Methods We included pregnant patients with vaginismus who presented at our obstetric emergency department between October 2016 and March 2017. All patients were interviewed by one expert psychiatrist and gynecologist using a standardized questionnaire. The State-Trait Anxiety Inventory (STAI) was used to determine anxiety and depression levels. Patients were prospectively followed until their postpartum period and were interviewed by the same experts after delivery. Sixteen weeks after hospital discharge, we contacted all patients via phone. All the information was simultaneously recorded in written form. Results Twenty pregnant patients with vaginismus were included (85% primary, 15% secondary). Most women described a conservative family background (70%) in which they received little or no sexual education (60%). All women described a feeling of anxiety and anger immediately before sexual intercourse and 40% have never sought medical consultation regarding their vaginismus before. Only 50% reported regular follow-up visits during their pregnancy (without vaginal examination), whereas 25% reported irregular follow-up visits with subjectively bad experiences during attempts of vaginal examinations. Conclusion Pregnant women with vaginismus are at risk of non-follow-up during their pregnancy due to underlying feelings of shame and experienced lack of understanding by medical staff. Obstetricians should carefully and attentively approach pregnant women with vaginismus in order to ensure adequate medical care during pregnancy.

Background:The Mood Disorder Questionnaire (MDQ) is a frequently used screening tool for the early detection of Bipolar Disorder (BD), which is often unrecognized or misdiagnosed at its onset. In this study, data from Tunisia has been used to evaluate the psychometric properties of the Arabic MDQ.Methods:The sample included 151 patients with a current major depressive episode. The Arabic adapted version of the Structured Clinical Interview for DSM-IV-TR was used to formulate a diagnosis, yielding 62 patients with BD and 89 with unipolar Major Depressive Disorder (MDD). Principal component analysis with parallel analysis was used to establish the spontaneous distribution of the 13 core items of the MDQ. Confirmatory Factor Analysis (CFA) was used to check the available factor models. Receiver Operating Characteristic (ROC) analysis was used to assess the capacity of the MDQ to distinguish patients with BD from those with MDD.Results:Cronbach’s α in the sample was 0.80 (95%CI: 0.75 to 0.85). Ordinal α was 0.88. Parallel analysis suggested two main components, which explained 59% of variance in the data. CFA found a good fit for the existing unidimensional, the two-factor, and the three-factor models. ROC analysis showed that at a threshold of 7, the MDQ was able to distinguish patients with BD from those with MDD with extraordinary negative predictive value (0.92) and a positive diagnostic likelihood ratio of 3.8.Conclusion:The Arabic version of the MDQ showed good measurement properties in terms of reliability, factorial validity and discriminative properties.

Neuropsychiatric manifestations in Sjögren’s syndrome are common and can occur not only during its course, but also at the onset of the disease. Depression and anxiety were the most frequently described symptoms. However, the association with bipolar disorder seems to be rare and not well documented. This case report presents a patient with bipolar disorder as comorbidity with Sjögren’s syndrome, suggesting that bipolar disorder could be associated with this autoimmune disease, which could lead to delaying diagnosis and treatment. A better analysis of the clinical background should be done by psychiatrists so to help early diagnosis and adapting prescription. Corticosteroids indicated in Sjögren’s syndrome should be prescribed with caution in bipolar disorder.

Le suicide est un problème de santé publique retrouvé dans la plupart des maladies psychiatriques notamment dans le trouble bipolaire (TB). Le but de ce travail était d´estimer la prévalence des tentatives de suicide (TS) et de déterminer les différents facteurs qui lui sont associés au sein d´une population de patients atteints de trouble bipolaire type I (TB I). Etude transversale et descriptive auprès de 150 patients. Nous avons eu recours à une fiche de renseignements, aux questionnaires d´évaluation des tempéraments affectifs, de l´addiction à l´alcool et des addictions aux drogues. La comparaison entre suicidants (23,3%, n = 35) et non-suicidants (76,7%, n = 115) a permis de dégager, les facteurs de risque de suicide suivants: l´addiction au cannabis, l´addiction aux psychotropes, un âge avancé, un antécédent familial de TB, de dépression, de TS et de décès par suicide, des antécédents personnels somatiques, un trouble de la personnalité associé en particulier la personnalité histrionique, un tempérament dépressif, un premier épisode thymique de nature dépressive, la récurrence des épisodes thymiques et une longue durée d´évolution de la maladie. On a également identifié deux facteurs protecteurs: l´acide valproïque et un nombre plus élevé de frères et sœurs. En étude multivariée les facteurs de risque étaient: l´âge, un antécédent familial de TB, un antécédent familial de TS et l´addiction au cannabis. Une attention particulière se doit d'être portée aux déterminants associés aux comportements suicidaires chez les patients atteints de TB I afin d'adopter des stratégies préventives et thérapeutiques efficaces.

Background:The perception by mental health service staff of respect for users' rights is a fundamental component of organizational well-being. The objective of this work is to examine how cultural differences and the working context can influence the perception of respect for users' rights in mental health professionals in the Mediterranean area.Methods:An observational survey carried out in four different mental health networks in four countries of the Mediterranean area (Tunisia, North-Macedonia, Italy, Palestine). Each invited participant fulfilled a format on socio-demographic information and coded the Well-Being at Work and Respect Right Questionnaire (WWRR). All data were encrypted and analysed using the Statistical Package for Social Sciences (SPSS) version 20. The Games-Howell post-hoc test was used to assess differences between countries. The Games-Howell test does not assume equal variances and sample sizes. Eta-squared (η2) was used as a measure of effect size in the ANOVA (η2around 0.01, 0.06, and 0.14 are considered small, medium, and large, respectively).Results:The sample included 590 professionals working in the mental health field. The four countries showed statistically significant differences with regards to the quality rights assessment tool. Participants from Italy reported, on average, the highest scores across the questions. There were also differences across the countries about the perception of the impact of available resources on the effectiveness of care (η2 = 0.106).Conclusion:Our findings offer a useful insight into the perception of the quality of mental health services, especially from a users’ rights point of view.

Background: The Well-Being at Work and Respect for human Rights Questionnaire (WWRR) was conceived based on the hypothesis that the perception of respect for users' rights is an essential element of well-being in the workplace in healthcare. The objective of the study is to examine the principal components of the WWRR. Methods: A random sample representative of a set of professionals working in three different healthcare networks in Tunisia, North-Macedonia, and Italy was enrolled (n=426). Each professional completed a questionnaire on sociodemographic data and the WWRR. The WWRR consists of six items on beliefs about: satisfaction at work, users’ satisfaction, organization at work, respect of users’ and staff human rights, adequacy of resources. A seventh item assesses the perceived needs of personnel. Correlation between the items was evaluated by analysing the principal components with Varimax rotation and Kaiser normalization (which included all components with an Eigen value> 1). Results: A single factor covered over 50% of the variance, all the items of the questionnaire were closely related and compose a single factor. Tunisia presented some differences regarding the item about the human rights of staff. Conclusion: Satisfaction with the respect for the rights of users is strongly correlated with the other factors that are part of the concept of the organizational well-being of health care providers. The WWRR provides a means of measuring this important and often neglected dimension.

Introduction:schizophrenia, bipolar disorder and schizoaffective disorders are severe mental illnesses (SMI) associated with high levels of co-morbid psychopathology and premature mortality. Reducing delays in accessing services and providing early intervention are key strategies in preventing morbidity and mortality associated with these diseases. The pathways to psychiatric care have been studied in many countries worldwide. To the best of our knowledge, no study on this subject has so far been conducted in Tunisia. The purpose of the present study was to understand the pathways of care adopted by patients, to determine the care delay and to explore the relationship between delayed consultation and socio-demographic and clinical variables. Methods:this is a cross-sectional descriptive study conducted at the Department Psychiatry A of Razi Hospital including patients with SMI consulting the outpatient clinic between January and March 2018. Data was collected by one medical investigator who conducted face-to-face interviews with patients using a questionnaire based on the World Health Organization's "Pathway Questionnaire". Data analysis was done using the SPSS software version 17. A multivariate analysis was performed to study the relation between delayed consultation and socio-demographic and clinical variables. Results:a total of 232 patients responded to the questionnaire. The average age was 41.3 years ± 10.1 and the gender ratio was 1.2. More than the third of the study population consulted a traditional healer in the first place and sixty percent of the patients had recourse to a medical doctor. The average consultation delay was 15 months (±23.0) with a median of 6 months. The delay was more than 6 months in around half of the cases. The symptoms that motivated the first consultation were hallucinations, sleep disorders and aggressive behavior. The main reason of delayed consultation was lack of knowledge about psychiatric symptoms followed by illness beliefs and insidious onset of the illness. The multivariate analysis showed a significant relationship between aggressive behavior and non-delayed consultation. Conclusion:the principal recommendations are to strengthen public education and awareness about SMI in the Tunisian population and to implement an early detection program of these disorders.

Background Stigma among healthcare providers is a barrier to the effective delivery of mental health services in primary care. Few studies have been conducted in primary care settings comparing the attitudes of healthcare providers and experiences of people with mental illness who are service users in those facilities. Such research is necessary across diverse global settings to characterize stigma and inform effective stigma reduction. Methods Qualitative research was conducted on mental illness stigma in primary care settings in one low-income country (Nepal), two lower-middle income countries (India, Tunisia), one upper-middle-income country (Lebanon), and three high-income countries (Czech Republic, Hungary, Italy). Qualitative interviews were conducted with 248 participants: 64 primary care providers, 11 primary care facility managers, 111 people with mental illness, and 60 family members of people with mental illness. Data were analyzed using framework analysis. Results Primary care providers endorsed some willingness to help persons with mental illness but reported not having appropriate training and supervision to deliver mental healthcare. They expressed that people with mental illness are aggressive and unpredictable. Some reported that mental illness is incurable, and mental healthcare is burdensome and leads to burnout. They preferred mental healthcare to be delivered by specialists. Service users did not report high levels of discrimination from primary care providers; however, they had limited expectations of support from primary care providers. Service users reported internalized stigma and discrimination from family and community members. Providers and service users reported unreliable psychiatric medication supply and lack of facilities for confidential consultations. Limitations of the study include conducting qualitative interviews in clinical settings and reliance on clinician-researchers in some sites to conduct interviews, which potentially biases respondents to present attitudes and experiences about primary care services in a positive manner. Conclusions Primary care providers’ willingness to interact with people with mental illness and receive more training presents an opportunity to address stigmatizing beliefs and stereotypes. This study also raises important methodological questions about the most appropriate strategies to accurately understand attitudes and experiences of people with mental illness. Recommendations are provided for future qualitative research about stigma, such as qualitative interviewing by non-clinical personnel, involving non-clinical staff for recruitment of participants, conducting interviews in non-clinical settings, and partnering with people with mental illness to facilitate qualitative data collection and analysis.

In many international studies, rates of completed suicide and suicide attempts have a seasonal pattern that peaks in spring or summer. This exploratory study investigated the association between solar insolation and a history of suicide attempt in patients with bipolar I disorder. Solar insolation is the amount of electromagnetic energy from the Sun striking a surface area on Earth. Data were collected previously from 5536 patients with bipolar I disorder at 50 collection sites in 32 countries at a wide range of latitudes in both hemispheres. Suicide related data were available for 3365 patients from 310 onset locations in 51 countries. 1047 (31.1%) had a history of suicide attempt. There was a significant inverse association between a history of suicide attempt and the ratio of mean winter solar insolation/mean summer solar insolation. This ratio is smallest near the poles where the winter insolation is very small compared to the summer insolation. This ratio is largest near the equator where there is relatively little variation in the insolation over the year. Other variables in the model that were positively associated with suicide attempt were being female, a history of alcohol or substance abuse, and being in a younger birth cohort. Living in a country with a state-sponsored religion decreased the association. (All estimated coefficients p

Background Vaginismus affects up to 1% of the female population and often represents a physical manifestation of an underlying psychological problem. Our objective was to investigate the psychosomatic impact of vaginismus in pregnant women and evaluate the quality of their therapeutic care in Tunisia. Methods We included pregnant patients with vaginismus who presented at our obstetric emergency department between October 2016 and March 2017. All patients were interviewed by one expert psychiatrist and gynecologist using a standardized questionnaire. The State-Trait Anxiety Inventory (STAI) was used to determine anxiety and depression levels. Patients were prospectively followed until their postpartum period and were interviewed by the same experts after delivery. Sixteen weeks after hospital discharge, we contacted all patients via phone. All the information was simultaneously recorded in written form. Results Twenty pregnant patients with vaginismus were included (85% primary, 15% secondary). Most women described a conservative family background (70%) in which they received little or no sexual education (60%). All women described a feeling of anxiety and anger immediately before sexual intercourse and 40% have never sought medical consultation regarding their vaginismus before. Only 50% reported regular follow-up visits during their pregnancy (without vaginal examination), whereas 25% reported irregular follow-up visits with subjectively bad experiences during attempts of vaginal examinations. Conclusion Pregnant women with vaginismus are at risk of non-follow-up during their pregnancy due to underlying feelings of shame and experienced lack of understanding by medical staff. Obstetricians should carefully and attentively approach pregnant women with vaginismus in order to ensure adequate medical care during pregnancy.

This chapter provides an overview of the current situation and the challenges Tunisia faces in the field of dementia care. Tunisia is a country in full demographic transition, witnessing an ageing of its population and an increase in dementia incidence and prevalence. There is growing awareness that the healthcare system needs to be better oriented towards this emerging problem. During the last 10 years, a number of public and private initiatives were implemented to improve diagnosis, treatment, training, and research on dementia. The major challenges facing dementia care in Tunisia include the need for early diagnosis and intervention, better coordination of care circuits, wider implementation of day care and residential care with the concurrent establishment of rigorous quality standards, and financial and psychological support for caregivers. Currently, a National Dementia Strategy is being developed in order to address these challenges. There is growing awareness among politicians and healthcare providers that the healthcare system needs to be more oriented towards the emerging problem of dementia in Tunisia. During the last ten years, a number of public and private institutions with focus on dementia care have been created. However, family members remain the cornerstone of dementia care in Tunisia. Currently, a National Dementia Strategy is being developed in order to address the following challenges: (1) the need for early diagnosis and intervention; (2) better coordination of care circuits; (3) wider implementation of day care and residential care with the concurrent establishment of rigorous quality standards; and (4) financial and psychological support for caregivers.

Vaginismus in one of the most frequent causes of non-consummation of marriage, and of infertility, in Arab-Muslim societies. Cognitive behavioural therapy (CBT) proved to be effective, but it is important to consider the cultural context of the patient attending CBT for vaginismus. The aim of our study was therefore to draw attention to the belief systems and behaviours linked to female sexuality and couple relationship in the Arab-Muslim culture. We present a series of four patients representative of the local culture and show how treatment strategies were adapted to fit these behaviours and belief systems, as well as environmental factors. We found that excessive closeness of family members, allowing the family to be intrusive and exercising pressure on the couple, a strict education which highly values virginity, transmits fear of ‘the male’ and fear of sex, and which links sex with pain, were the common denominator of all patients of our case series. We adapted the classical CBT strategies for vaginismus to our cultural context. The educational component was enlarged. Cognitive techniques were used to modify specific traditional beliefs. The integration of the family, and not only of the partner, into the treatment process proved uniquely beneficial for the patients.

Bipolar mood disorder (BD) is a severe debilitating mental disorder, and a number of patients are resistant to standard treatment. We report two clinical cases of treatment resistant mania (TRM) responsive to clozapine. Mrs. A and Mrs. B are two BD patients aged 30-year-old and 34-year-old respectively. They had a similar age of BD onset at 16 years old. They both had five manic episodes at least before they had the TRM. Mrs. A had a history of allergy to haloperidol. She presented a manic episode that was unresponsive to olanzapine 20 mg daily, risperidone 4 mg daily and lithium 1,250 mg daily. Mrs. B had a history of a mania non-responsive to the association of lithium and olanzapine 20 mg daily and a history of severe depression under lithium and haloperidol 30 mg daily. She presented a manic episode resisting the association of lithium 1000 mg daily, carbamazepine 600 mg daily, quetiapine 100 mg daily and chlorpromazine 150 mg daily. They both eventually received clozapine uptitrated gradually to 300 mg daily with lithium (1,000-1,250 mg daily) with satisfactory clinical response within three weeks of starting clozapine. Clozapine seems to be efficacious in TRM. Further randomized clinical trials are needed to strengthen its evidence based indication in TRM.

Highlights • We implemented a helpline accessible throughout the country, including those without access to Internet. • Our model is a medico-economic-social volunteering model which integrates medical students, child and adolescent psychiatrists, psychiatrists, psychologists, a facilitator technical platform, and social services. • An intervention method which is carried out immediately and on demand, adapted to different categories (medical staff, child, adult) and ranging from simple psychoeducation to specialized care by therapists competent in victimology, suicidology or addictology., In order to manage the urgent psychological need for support in response to the anticipated reaction of the population to the COVID-19 pandemic, we developed a new psychological crisis intervention model by implementing a centralised psychological support system for all of Tunisia. We set up a helpline which is accessible throughout the country, including those without access to Internet. This model integrates medical students, child and adolescent psychiatrists, psychiatrists, psychologists and social services to provide psychological intervention to the general population and medical staff. It will make a sound basis for developing a more effective psychological crisis intervention response system.

Depression is considered a global public health problem especially in the developed countries, where depression is the leading cause of morbidity.To determine the point prevalence and the severity of depression in primary health care, to define the profile of patients suffering from depression and consulting in primary health care. To identify risk factors for depression, in particular chronic co-morbid conditions.Our study was a descriptive and analytical cross-sectional study of 1000 patients aged over 18 years consulting in ten primary care structures. It took place during a period of six successive days from 8 to 13 April 2012. Depression was assessed by the 9-item-Patient Health Questionnaire (PHQ-9).In our sample, the average age was 42,4 years ranging from 18 to 89 years. Females were predominant with 66,6 %. According to the PHQ-9, the prevalence of major depressive episode (MDE) was 12,1 %. It was higher among women (13,5%) compared with men (9,3%) with an odds ratio of 1,5. The highest prevalence of MDE (19%) was noted in the age group of 45-54 years. The most prevalent clinical signs found in our population were sleep disorders (29,7%) and suicidal ideation (28,4%). Among patients with MDE, only 10% were followed up for depression. Major depressive disorder was significantly associated with comorbid chronic diseases (p0,001), especially diabetes (p = 0,043, OR = 2,1), musculoskeletal diseases (p = 0,028, OR = 2,1) and pulmonary diseases (p = 0,001 , OR = 5,5). Having one comorbid chronic condition multiplied the risk of having a MDE by 2,2. This risk was 3,2 for two or more comorbid chronic conditions.Depression in primary care remains a largely underdiagnosed and undertreated condition. Patients with chronic disorders are particularly vulnerable.