The Challenges of Determining the Prevalence of Depression Among Indian Adolescents
Depression is a common illness worldwide, occurring in all age groups (Keren & Tyano, 2006), with estimates suggesting 280 million people (3.8% of the population) worldwide suffer from depression (World Health Organization, 2023). Depression is the leading cause of disability worldwide (Reddy, 2010), estimated to occur among 1.1% of adolescents aged 10-14 years and 2.8% of adolescents aged 15-19 worldwide (World Health Organization, 2021). Research is beginning to identify and estimate the prevalence of depression in adolescents globally, however data from India is currently incomplete and sometimes conflicting.
Studies in India use varying methods to assess prevalence in adolescents, with some using one-stage sampling and some using two-stage sampling. One stage sampling involves using a screening instrument, such as the Becks Depression Inventory-II, to assess Depression prevalence (Grover et al., 2019), whereas two stage sampling involves using an initial screening instrument, followed by an evaluation of the patient using either structured clinical interviews, such as the Mini International Neuropsychiatric Interview for children and adolescents (MINI-KID), or semi-structured interviews to evaluate patients using the criteria from the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition Text Revision (DSM-5-TR) or the International Classification of Diseases 11th Revision (ICD-11)(Grover et al., 2019). A pattern seen across many studies (e.g., Jha et al., 2017; Shukla et al., 2016; Singh et al., 2017) is studies using one-step sampling overestimate the prevalence of depression (Grover et al., 2019). For example, using one-stage sampling, Jha et al. (2017) used Becks Depression Inventory-II to estimate the prevalence among 1485 14–18-year-olds, revealing a prevalence of 49.2%. Whereas Jayanthi and Thirunayukarasu (2015) used two-stage sampling with 2432 14- to 17-year-olds, by screening them using the MINI-KID depression module, and then having them assessed by a psychiatrist. Prevalence was estimated to be 25%. Therefore, as prevalence estimates are so conflicted, there is a considerable gap in the research that needs to be filled; the prevalence of depression among adolescents in India should be estimated using a two-step screening method, so as to not overestimate the prevalence of depression, resulting in a potentially more accurate prevalence estimate.
Another issue arising from research estimating the prevalence of depression in adolescents in India is whether the measures used are culturally valid in India. The BDI (Beck’s Depression Inventory) has been validated (Basker et al., 2007) for use in screening adolescents in India for depression, however, the BDI-II has not been; the BDI-II differs from the BDI. The MINI-KID has been validated for use in India (Sheehan et al., 1998). Various studies use the ICD-10 classification to investigate the prevalence of depression in adolescents in India. For example, Russel et al. (2012) revealed a 6.07% prevalence of depression in a sample of 181 14–17-year-olds using the ICD-10 classification. Despite studies using the ICD-10 to diagnose depression, about 75% of 386 qualified psychiatrists who are members of the Indian Psychiatric Society and residing in India believe the ICD-10 was difficult to apply across cultures (Avasthi, 2014), calling into question the cultural validity of the ICD-10 for the diagnosis of depression in India, suggesting classifications should provide flexible guidelines for diagnosing depression to allow for cultural variation. This is especially important as it has been shown that words used to describe symptoms differ in their meanings across languages, therefore influencing prevalence rates (Nogurea et al., 2009; Smirnova et al., 2018). Hence, cultural validity is crucial to ensure language used in the measures is interpreted the same way and reflects the same construct across cultures, to ensure prevalence estimates reflect the true prevalence.
To conclude, there are concerns about the cultural validity of diagnostic tools and the validity of one stage sampling processes in diagnosing mental health disorders. From this, future estimates of the prevalence of depression in adolescents in India should strive to use a two-step sampling process using measures that have been validated for use to screen adolescents in India for depression.
References
Avasthi, A., Grover, S., Maj, M., Reed, G., Thirunavukarasu, M., & Garg, U. C. (2014). Indian Psychiatric Society-World Psychiatric Association - World Health Organization survey on usefulness of International Classification of Diseases-10. Indian Journal of Psychiatry, 56(4), 350–358. https://doi.org/10.4103/0019-5545.146522
Basker, M., Moses, P. D., Russell, S., & Russell, P. (2007). The psychometric properties of Beck Depression Inventory for adolescent depression in a primary-care paediatric setting in India. Child and Adolescent Psychiatry and Mental Health, 1(1), 1–7. https://doi.org/10.1186/1753-2000-1-8
Grover, S., Raju, V., Sharma, A., & Shah, R. (2019). Depression in children and adolescents: A review of Indian studies. Indian Journal of Psychological Medicine, 41(3), 216–227. https://doi.org/10.4103/ijpsym.ijpsym_5_19
Jayanthi, P., & Thirunavukarasu, M. (2015). Prevalence of depression among school going adolescents in South India. Int J Pharm Clin Res, 7(1), 61-3.
Jha, K., Singh, S., Nirala, S., Kumar, C., Kumar, P., & Aggrawal, N. (2017). Prevalence of depression among school-going adolescents in an Urban Area of Bihar, India. Indian Journal of Psychological Medicine, 39(3), 287–292. https://doi.org/10.4103/0253-7176.207326
Keren, M., & Tyano, S. (2006). Depression in Infancy. Child and Adolescent Psychiatric Clinics of North America, 15(4), 883–897. https://doi.org/10.1016/j.chc.2006.05.004
Noguera, A. V., Centeno, C., Carvajal, A., Tejedor, M. C., Urdiroz, J., & Martínez, M. (2009). Spanish “Fine Tuning” of Language To Describe Depression and Anxiety. Journal of Palliative Medicine, 12(8), 707–712. https://doi.org/10.1089/jpm.2009.0024
Reddy, M. (2010). Depression: The disorder and the burden. Indian Journal of Psychological Medicine, 32(1), 1–2. https://doi.org/10.4103/0253-7176.70510
Russell, P. S., Basker, M., Russell, S., Moses, P. D., Nair, M. K. C., & Minju, K. A. (2012). Comparison of a Self-rated and a Clinician-rated Measure for Identifying Depression among Adolescents in a Primary-care Setting. The Indian Journal of Pediatrics, 79(1), 45–51. https://doi.org/10.1007/s12098-011-0438-5
Sheehan, D., Lecrubier, Y., Harnett Sheehan, K., Janavs, J., Weiller, E., Keskiner, A., Schinka, J., Knapp, E., Sheehan, M., & Dunbar, G. (1998). The validity of the Mini International Neuropsychiatric Interview (MINI) according to the SCID-P and its reliability. European Psychiatry, 12(5), 232–241. https://doi.org/10.1016/s0924-9338(97)83297-x
Shukla, N. K., Shukla, M., Ahmad, S., Shukla, R., & Khan, Z. (2016). A cross-sectional study on depression among school going adolescent girls in Barabanki district, Uttar Pradesh, India. International Journal of Contemporary Pediatrics, 4(1), 178–181. https://doi.org/10.18203/2349-3291.ijcp20164601
Singh, M., Gupta, M., & Grover, S. (2017). Prevalence & factors associated with depression among schoolgoing adolescents in Chandigarh, north India. Indian Journal of Medical Research, 146(2), 205–215. https://doi.org/10.4103/ijmr.ijmr_1339_15
Smirnova, D., Cumming, P., Sloeva, E., Kuvshinova, N., Romanov, D., & Nosachev, G. (2018). Language Patterns Discriminate Mild Depression From Normal Sadness and Euthymic State. Frontiers in Psychiatry, 9, 1–11. https://doi.org/10.3389/fpsyt.2018.00105
World Health Organization. (2021, November 17). Mental health of adolescents. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/adolescent-mental-health
World Health Organization. (2023, March 31). Depressive disorder (depression). World Health Organisation. https://www.who.int/news-room/fact-sheets/detail/depression