Prevalence of Severe Depression among Adolescents in Rural Area of Odisha, India.

BACKGROUND: In adolescents, major depression is projected to rank the second most cause of human illness by the year 2022. Unfortunately, half of the depressed adolescents go undiagnosed in primary care settings.
OBJECTIVES: The objective is to estimate the prevalence of severe depression among rural adolescents and also to identify few epidemiological determinants causing severe depression. SETTINGS AND
DESIGN: This cross-sectional study included 341 adolescents from a selected village of Balasore, Odisha.
MATERIALS AND METHODS: A semi-structured questionnaire, and "Beck's Depression Inventory II" questionnaire for screening depression.
RESULTS: Only 24 (7%) of adolescents were found to be having severe depression. The subcategories of depression showed mild mood disturbance in 8.8%, borderline depression in 15.2%, and moderate depression in 12% individuals. Almost 267 (78.2%) were between 15 and 19 years of age. The mean age (standard deviation) of the participants was 16 ± 1.9 years. Majority of the participants belonged to joint family and lower middle-class status as per the Modified Kuppuswamy Scale.
CONCLUSION: Female gender was found to be significantly associated with depression (P = 0.006). Other contributory factors for depression were sleep duration (<6 h), parental fighting, and socioeconomic status. Copyright:

INTRODUCTION

Mental health account for 16% of the global burden of disease and injury in people aged 10–19 years. It is estimated that 190 million adolescents comprise over one-fifth of the entire population.[1] The World Health Organization defines adolescents as persons in the age group of 10–19 years.[2] Adolescence is a period of transition in terms of both physical and mental. During this phase, the adolescent develops stronger bonding with peer groups and romantic interest.[2] There is always physiological and psychological development during this part of life.[3]

Globally, depression is one of the leading causes of illness and disability.[2] Even in developed nation's depression is a known health burden among children, adolescents, and adults. One in four children in the age group of 13–15 years in India suffers from depression, which affects 86 million people in the South-East Asia region, the World Health Organization. In adolescents, major depression is projected to rank second-most cause of human illness by the year 2020.[4]

Unfortunately, half of the depressed adolescents go undiagnosed in primary care settings.[45] Declining physical exercise, overutilization of gadgets during bedtime affects the sleep quality thereby predisposing to rise of depression.[35] A number of literatures have also shown that sleep deprivation and depression both have bidirectional relationship.[6789] Depression can have affect on the academic performances of students, hence limiting their career opportunities.[101112131415]

Various researchers have shown different proportion of depression among school and college-going students in both urban and rural areas.[16171819] Due to the paucity of community-based studies on severe depression in this part of Odisha; this present study was conducted in one of the villages of Balasore district, Odisha with the following objectives.

To estimate the prevalence of severe depression among rural adolescents

To identify epidemiological determinants causing severe depression.

MATERIALS AND METHODS

Study design

This present community-based cross-sectional study was carried out among the adolescents in the age group of 10–19 years residing in rural areas of Balasore district, Odisha. Data were collected from October 2019 to December 2019. Balasore is one of the coastal districts of Odisha. The proportion of children currently attending school in the age group of 6–17 years is 89.9% and 92.5% in both rural and urban areas of Balasore district, respectively.

Sample size and sampling technique

The sample size was estimated based on the prevalence data from the existing literature.[5] Taking prevalence of depression as 30%,[5] with 20% relative precision and after applying a design effect of 1.5, the sample size was calculated as 336. Even though required sample size was 336, which with a nonresponse rate of 5% was increased to 354. Multistaged sampling method was adopted.

The first stage was cluster sampling where clusters were selected based on probability proportional to size. A list of all eligible adolescents residing in the selected villages was prepared with help of the Integrated Child Development Scheme supervisors, AWW, and ASHA. The second stage of sampling involved selecting the adolescents from within the clusters by simple random sampling. Probability proportionate to size strategy was adopted to enroll required number of participants from each village. From each house, one participant was selected. If one house consists of both boy and girl of the same age group then lottery system was adopted to choose a participant and to avoid selection bias. Data collection was done by a team comprising a final year psychology student and a 2nd year MBBS student on every Sundays and public holidays to ensure the presence of adolescents at home.

Study tool

A semi-structured questionnaire was administered; which included questions related to sociodemographic characteristics and other personal details. The socioeconomic status was calculated using Modified Kuppuswamy Scale. Beck's Depression Inventory II” screening tool was used to assess depression. It comprised 21 items with multiple choice answers, and each answer being scored on a scale of values 0–3 with the maximum possible score of 63. A score of 0–13 was considered as normal, 14–19 as mild/borderline depression and 20–28 as moderate depression, and 29–63 as severe depression.[2021]

Inclusion and exclusion criteria

Adolescents residing for more than 6 months in the selected village were included in the study. Participants on treatment for chronic illness, or any medically diagnosed mental illness and also those not giving consent were excluded from the study.

Statistical analysis

Statistical analysis data were entered into SPSS software version 22 (SPSS Inc., Chicago, IL, USA). The prevalence is expressed as percentages with 95% confidence interval (CI). Independent variables that were found to be statistically significant in univariate analysis were considered for the logistic regression model to determine the important correlates. P ≤ 0.05 was considered statistically significant.

Ethical clearance

Permission to carry out the study was obtained from the Institutional Ethical Committee of the Government Medical College and Hospital, Balasore. Informed consent was obtained from parents/guardians after explaining them about the purpose of the study. Assent was also obtained from the participants.

RESULTS

Of the total 354 adolescents, seven were excluded due to refusal to participate in the study or who were not present in the house even after three separate visits, and other six had permanently migrated from the study area. Out of 341 participants selected, 229 (67.2%) were male and 112 (32.8%) were female. Around 74 (21.7%) were in the age group of 10–14 years and 267 (78.2%) were between 15 and 19 years of age. The mean age (standard deviation) of the participants was 16 ± 1.9 years. According to the type of family, 46 (13.5%) participants were from nuclear family and 295 (86.5%) participants were from joint family.

148 (43.4%) showed depression and 193 (56.5%) were found to be having no depression. The subcategories of depression show mild mood disturbance in 8.8%, borderline depression in 15.2%, 12%, and 7% with moderate depression had severe depression.

Table 1 depicts univariate analyses of depression with the socio-demographic factors. Females were more depressed compared to males. Based on the educational qualification, the majority of 199 (58.4%) were into primary school, secondary schooling 8 (2.4%), high school, and above 134 (39.2%). More than half 195 (57.1%) were sleeping for <6 h in the night time and the rest 146 (42.9) for >6 h.

Table 1

Prevalence of depression as per various demographic characteristics (n=341)

Characteristics	Total, n (%)	Proportion with depression, n (%)
Age (years)
10-14	74 (21.7)	4 (5.4)
15-19	267 (78.2)	20 (7.4)
Gender*
Female	112 (32.8)	14 (12.5)
Male	229 (67.2)	10 (4.3)
Type of family
Nuclear	46 (13.5)	3 (6.5)
Joint/extended	295 (86.5)	21 (7.1)
Socioeconomic status*
≥Upper middle	84 (24.6)	11 (13.1)
≤Lower middle	257 (75.4)	13 (5.06)
Education level of study participants*
Up to primary level	199 (58.4)	13 (6.5)
Middle school	8 (2.4)	3 (37.5)
High school and above	134 (39.2)	8 (5.9)
Mother education
≥High school	168 (49.2)	9 (5.3)
Primary	173 (50.8)	15 (8.6)
Daily sleeping hours*
≤6	195 (57.1)	21 (10.7)
≥6	146 (42.9)	3 (2.0)
Play outdoor games*
Never	133 (39.0)	16 (12.0)
>3 times in a week	101 (29.6)	1 (0.9)
<3 times in a week	107 (31.4)	7 (6.5)
Parental fighting*
No	41 (12.0)	7 (17.0)
Yes	300 (88)	17 (5.6)

*P <0.05 is significant

Table 2 depicts logistic regression analysis of factors related to depression. Females tend to be more depressed than males (adjusted odds ratio [AOR] = 0.38; CI 95%: 0.15–0.98). This difference across the gender was found to be statistically significant (P = 0.006). Participants sleeping for lesser duration have higher chances of developing depression compared to those who sleep more (AOR = 5.1; CI 95%: 1.4–18.2). It has been observed that participants witnessing regular parental fighting have three times more chances of becoming depressed compared to their counterparts (AOR = 3.1; CI 95%: 1.1–9.0). Furthermore, socioeconomic status seems to be playing a contributory role in depression (AOR = 3.4; CI 95%: 1.3–9.0).

Table 2

Logistic regression analysis of factors related to depression in the study population (n=341)

Variables	Category	AOR (95% CI)	UOR (95% CI)
Gender	Male		-
	Female	0.38 (0.15-0.98)	0.31 (0.13-0.74)
Play outdoor games	Never	N/A	-
	>3 times in a week		0.07 (0.00-0.56)
	<3 times in a week		0.51 (0.20-1.29)
Hours of sleep	≥6	-	-
	≤6	5.1 (1.4-18.2)	5.7 (1.6-19.6)
Education level of study participants	Up to primary		-
	Middle school	4.2 (0.70-25.6)	8.5 (1.84-39.95)
	Above high school	0.89 (0.33-2.4)	0.90 (0.36-2.25)
Parental fighting	Yes		-
	No	3.1 (1.1-9.0)	3.42 (1.32-8.85)
Socioeconomic status	≤Lower middle		-
	≥Upper middle	3.4 (1.3-9.0)	2.8 (1.21-6.58)

AOR: Adjusted odds ratio, UOR: Unadjusted odds ratio, CI: Confidence interval, NA: Not applicable

DISCUSSION

Our study showed that 7.03% of participants had severe depression which is similar to the findings of previous studies.[202122] A study in North India reported the prevalence of depression to be 39% which is much higher compared to our findings.[23] Such variation could be because of different methods used for the assessment of depression and different baseline variables of study population.

In this study, mid and late adolescent age group, i.e., 15–19 years were found more depressed, this corroborates with the finding of Jayashree et al.,[23] on the contrary Jha et al.[20] and Shukla et al.[24] found significant association between higher proportion of depression with the increasing age which may be attributed to factors such as more academic and parental pressure compared to lower standards.[25]

Findings of higher depression among females well corroborate with some of the previous studies.[16172023] There can be various reasons such as fear of getting married at an early age, especially in rural areas, incomplete education, hormonal changes, and extra work at home. However, Umesh et al.[21] and Chauhan et al.[22] did not support any similar association.

The type of family seems to be having no role in depression which is also explained by Jayashree et al.[23] and Jha et al.[20] In contrast to our study, a finding by Umesh et al.[21] shows a statistically significant difference with type of family.

It was observed that adolescents who were never engaged in playing any outdoor games were more depressed compared to others. This is in line with the finding of Nair et al. and[16] Chauhan et al.[22] We also found an association between sleep deprivation (i.e., sleeping <6 h) and depressions. In this regard, our results are consistent with other studies.[1112]

In addition, we found socioeconomic status of the family and parental fighting to be significantly (P < 0.05) associated with depression. This observation is in consonance with a previous study done by Nair et al. and[16] Jayashree et al.[23]

CONCLUSION

This is a small effort by the authors in rural area of Odisha to show the proportion of depression and few stressors causing depression such as sleep duration, outdoor sports activities, socioeconomic status, and parental fighting, and education level of participants.

Limitations

A cause-and-effect relationship is difficult to elicit due to cross-sectional study. There is underrepresentation of female population in our study. Other sensitive topics such as addictions in the family, and sexual abuse were not addressed due to difficulty in opening up of adolescents as the interview was conducted during home visit.

Recommendation

Researchers should be encouraged for undertaking more studies on mental health issues, especially in rural areas

Behavior change and communication materials with more focus on the younger age group children.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.