Prevalence of depression and anxiety among school going adolescents of Delhi: A cross-sectional study

ABSTRACT

Introduction:

According to UNICEF, among adolescents’ mental disorders, depression and anxiety account for 42.9% of cases. As per the National Mental Health Survey (NMHS) (2015-2016) of India; the Prevalence of Depressive Episodes and Recurrent Depressive Disorder and Phobic anxiety disorder among adolescents is 2.6% and 1.3%, respectively. The well-being and development of adolescents are directly related to the quality of their environment and early experiences of life. To understand the current mental health of adolescents the present study was initiated.

Methods:

A cross-sectional survey was conducted among 679 students aged 10-19 years at selected schools in South Delhi, India. Initially after the written informed consent procedure, a self-reported questionnaire was administered to collect data on socio-demographic variables and the Patient Health Questionnaire (PHQ-4). Descriptive statistics, Chi-square, univariate, and multivariate logistic regression were used to examine associations between variables under examination with anxiety and depression.

Results:

In the present survey, the mean age of study participants was 13.43 years, 386 (56.85%) participants were male. The overall prevalence of depression and anxiety among adolescents was found to be 25.92% and 13.70% respectively. The prevalence of depression was significantly higher among students who do not have sleep satisfaction (35.9% vs. 23.0%, P = 0.001) and among those who experience anxiety (58.1% vs. 20.8%, P = 0.000) than others. Similarly, the prevalence of anxiety was found significantly higher with increasing age (χ2, P = 0.001), increasing education levels (χ2, P = 0.001), sleep quality (χ2, P = 0.009), sleep satisfaction (χ2, P = 0.000), relationship status (χ2, P = 0.032) and depression status (30.7% vs. 7.8%, P = 0.000). Based on Multivariate analyses, higher education level (AOR: 1.53, 95%CI: 1.06–2.20) and anxiety (AOR: 4.88, 95%CI: 3.07–7.76) were associated with depression. Anxiety was associated with increasing age (16–19 years) (AOR: 3.35, 95%CI: 1.59–7.06) and depression (AOR: 5.18, 95%CI: 3.26–8.25).

Conclusion:

The present study suggests that the prevalence of depression and anxiety among school-going adolescents is 25.92% and 13.70%, respectively. The most common associated risk factors are increasing education level, sleep satisfaction, and anxiety and depression. The information may contribute to the development of preventive and control strategies for mental health conditions among adolescents for their welfare and well-being.

Introduction

The World Health Organization (WHO) estimates that adolescents (10–19 years) make up one-sixth (~16%) of the world’s total population.[1] Adolescence is a crucial period of growth, development, and self-discovery, characterized by physical, emotional, and social changes. Adolescents are more vulnerable to various Mental Health Conditions (MHCs) as a result of these changes. Their well-being and development are directly related to the quality of the environment and the early negative experiences of life.[2] According to 2019 data, MHCs account for 10–20% of adolescents responsible for nearly 13% world’s global burden of disease and injury.[3,4] It has been observed that the majority of these MHCs (50%) start by the age of 14 years but remain unnoticed and untreated.[5] MHCs have increased (by about 4 million) in children and adolescents over the past 20 years. Common MHCs have become the second and eleventh leading cause of disease burden and disability among adolescents aged 10-14 years and 15–19 years respectively.[3,6] UNICEF considers, anxiety and depression to be significant concerns and account for 42.9% of all mental disorders.[6]

Globally, Depression is the most prevalent mental health issue affecting adolescents (4.4%). It is one of the leading causes of illness and disability, ranking 15^th among those aged 10–14 years and fourth among aged 15–19 years. Anxiety affects approximately 8% of children and adolescents globally.[3] Both anxiety and depression exhibit similar symptoms, like rapid and unexpected mood swings, and both have a profound impact on the overall well-being, development, and quality of life of adolescents. Depression and anxiety are comparatively more common among those aged (15–19) years (2.8% and 4.6%) as compared to those aged 10–14 years (1.1% and 3.6%).[3] Suicidal thoughts and behaviors are severe and potentially life-threatening outcomes. In India, the proportion of adolescents aged 10–19 years is 20.9%.[7] According to National Mental Health Survey (NMHS) (2015–2016); the Prevalence of mental disorders in the age group 13–17 years is 7.3%. The most prevalent MHCs in India are Depressive Episode and Recurrent Depressive Disorder (2.6%), Agoraphobia (2.3%), Intellectual Disability (1.7%), Autism Spectrum Disorder (1.6%), Phobic anxiety disorder (1.3%), and Psychotic disorder (1.3%).[8]

The importance of mental health has been mentioned under one of the Sustainable Development Goals (SDGs 3.4).[9] One of its targets is to reduce the overall number of early deaths from non-communicable diseases at least by one-third by 2030 and to prevent, promote, and treat mental health and well-being.[10] Adolescents’ mental health is crucial to all facets of their lives and is necessary for socioeconomic advancement, human Capita growth, and a more developed nation and planet.[11] On the other side, poor psychosocial development of adolescents can result in adulthood illnesses, such as an increased risk of injuries, substance abuse, and self-harm, which can have an impact on the quality and duration of later life.[12]

These factors, which are associated with risk-taking behaviors, stigma, strained social ties, and physical ill health, have a significant impact on school attendance and academic achievement.[13] Depression is also commonly associated with sleep problems and or disturbed circadian rhythm and is directly proportional to the severity of the condition.[14,15] The overall burden of poor mental health has grown more significantly since the COVID-19 epidemic.[16] Presently, Mental health services are the most neglected area among existing health care services. The elements that contribute include inaccurate assessment, lack of qualified healthcare professionals and resources, unawareness, a shortage of mental health specialists, poor socioeconomic situations, and the social stigma associated with being managed for a mental health condition.[17,18]

Purpose of the study

In Developing countries like India, the field of mental health is underdeveloped and unfocused. Triple dividend health advantages—for adolescents today, for adolescents’ future lives, and for the next generation—will result from promoting and safeguarding adolescents’ mental health. These benefits will also extend to the public health, economy, and demographic sectors. In adulthood, morbidity and premature death may be reduced by promoting appropriate eating and sleeping habits, as well as the early identification and treatment of common issues (mental, social, and sexual). Due to ignorance issue on mental health, there is a paucity of data and related issues. Therefore, available data cannot be used to advance sensible health policies that take into account the importance of mental health for today’s adolescents and tomorrow’s adults. Thus, the primary objective of the current study was to determine the prevalence of depression and anxiety among adolescents, about the range of the current adolescent conditions, Secondly, to identify and understand the associated factors with these conditions.

Materials and Methods

A self-reported questionnaire-based cross-sectional study was conducted among adolescent students aged 10–16 years (Grades 6–12) at a selected school in south Delhi, India. Enrolling students in the survey used a multistage sampling procedure.

Step 1 - Within a 10-kilometer radius, several schools (the Primary Sampling Unit) were initially selected based on their viability. The selected schools› respective class teachers and the principal head of the school were asked for permission.

Step 2 - Then, in the selected schools each class was divided into several sections.

Step 3 - Sections were randomly selected and students in the selected sections were then eligible to participate in the study.

Adolescents of either sex, aged between 10-19 years, who gave consent and were willing to enroll in the survey and present on the day of the survey were only included.

Sample size calculation

In the most recent study, Kumar et al. (2019)[19] reported a prevalence rate of depression of 47.9% focusing on the adolescent population. For multistage sampling, the relative margin of error and the design effect are usually considered to be 10% and 1.5, respectively.[20] The sample size is calculated using the following formula -

Here, n = number of participants; z = 1.96 (95% confidence level); p = prevalence estimate (.479); q = (1- p); e = margin of error; de = design effect for multistage sampling.

This gives a sample size of 575 in the proposed survey. The sample size for the current study was 632, with the assumption of 10% nonrespondents (drop-outs). To establish sufficient power for the investigation, however, 700 subjects were included.

Data collection tools

A Performa was prepared in English and Hindi language, which included basic socio-demographic data, lifestyle-related details, and a Patient Health Questionnaire (PHQ-4) scale for assessing depression and anxiety. The Performa was divided into five sections, including informed consent and the date the survey was conducted, in the initial part [Annexure 1].

Section A - Basic socio-demographic information including age, sex, class, height (in cm), weight (in Kg), parents› education and occupation, total monthly family income, and socio-economic status (SES) as per Modified Kuppuswamy Scale.[21]

Section B – A validated questionnaire Patient Health Questionnaire (PHQ-4) was used to assess depression and anxiety.

Patient Health Questionnaire 4 (PHQ-4)[22] - The PHQ-4 is a reliable and valid tool that can screen core symptoms of depression and anxiety. In a study involving Adolescent girls, Cronbach’s α of the PHQ-4 was found to be 0.81.[23] It is available in both English and Hindi language and employed in the present study.[24]

Section C – Details of social factors, such as Type of family, number of family members, relationship status, quality of relationship with siblings and classmates.

Section D - Comprised of questions about lifestyle-related information. It was collected by asking questions concerning dietary habits, regular physical activity, Addiction (Smoking/Tea/Coffee/Alcohol, etc.), and use of the internet, Mobile, and television with regard to screen time.

Section E - Personal history of the participants, i.e. diet, appetite, bowel and bladder habits, general health, and personal hygiene.

Before initiating the survey procedure, this pilot test of the Performa was done on 30 participants. Further, required modifications were done and Performa was finalized for the survey.

Data collection procedure

The data collection was done during Mar’22 to June’22. Before distributing the questionnaire, orientation about the Performa was given to the students and they were informed about the importance of responding to each statement of the questionnaire very carefully. Then, the self-administered survey Performa was distributed to each participant separately. The average time for the completion of Performa by students was approximately 15–20 minutes.

Consent - To protect respondents’ rights, the class teacher was asked to take verbal informed consent. To obtain informed assent from the respondents, a written informed assent form was used before data collection.

Confidentiality - Anonymity is ensured by asking respondents not to write their names on the survey forms or other identifying information. Privacy is maintained by keeping the collected information confidential.

Data management and analysis

The collected data was then classified, and the different variables of the Performa were coded and double-checked. Incomplete Performa filled by the participants were not considered for further analysis. Data entry, data editing, data cleansing, and double data elimination were done in Microsoft Excel. Statistical evaluation was done using statistical package for social sciences (SPSS v. 26) software. Descriptive statistics was used to describe the sample characteristics and Chi-Square (χ2) was used to observe association between variables. The level of significance is considered at P ≤ .05. The odds ratio for a 95% confidence interval is presented using Univariate and multivariate logistic regression. Logistic Regression was done using the Block 1 Forward stepwise Method (Likelihood Ratio), to predict the power of association between dependent and independent variables and the likelihood of the occurrence of the event (Depression and anxiety).

Ethical considerations

The study was initially approved by the Institutional Review Board (IRB) and then ethically approved by the Institutional Ethical Committee (IEC) of All India Institute of Ayurveda, IEC-AIIA/2021-P81. The study was conducted in accordance with the Institutional Ethical committee.

Results

A Total of 679 filled Performa were considered for further analysis [Figure 1].

Figure 1.

Study enrolment flow chart

The participants’ mean age was 13.43 years, with a range of years (10–19), and included 386 males (56.85%) and 293 females (43.15%) overall. Among the participants, 367 (54.05%) belong to the age group 13–15 years, class 9–10^th (46.69%), and middle SES (78.20%). Among all, 59.9% only have adequate sleep quality, engage in regular physical activities (78.65%), are satisfied with their sleep (77.47%), sleep six to eight hours (59.94%), non-smokers (98.82%), and are nontobacco users (99.56%) and have no associated addiction (81.29%). [Table 1] According to the PHQ-4 scale, the overall prevalence of depression and anxiety among adolescents was found to be 25.92% and 13.70%, respectively, in the present study.[Figure 2] Normal, mild, moderate, and severe grading is found in 62.30%, 26.07%, 8.98%, and 2.65% of participants, respectively, in terms of severity.

Table 1.

Descriptive Distribution of variables, and association with depression and anxiety

Domain	Variables	Total (n=679)		Depression				P	Anxiety				P
				Positive*		Negative			Positive#		Negative
		n	(%)	n	(%)	n	(%)		n	(%)	n	(%)
Age (in years)	10–12	217	31.96	51	23.5	166	76.5	0.057	15	6.9	202	93.1	<0.001
	13–15	367	54.05	91	24.8	276	75.2		57	15.5	310	84.5
	16–19	95	13.99	34	35.8	61	64.2		21	22.1	74	77.9
Sex	Male	386	56.84	108	28	278	72	0.16	48	12.4	338	87.6	0.27
	Female	293	43.15	68	23.2	225	76.8		45	15.4	248	84.6
Education/Class	6–8th	272	40.06	69	25.4	203	74.6	0.018	23	8.5	249	91.5	0.001
	9–10th	317	46.69	73	23	244	77		49	15.5	268	84.5
	11–12th	90	13.25	34	37.8	56	62.2		21	23.3	69	76.7
SES	Upper	34	5.00	7	20.6	27	79.4	0.123	5	14.7	29	85.3	0.40
	Middle	531	78.20	131	24.7	400	75.3		68	12.8	463	87.2
	Lower	114	16.79	38	33.3	76	66.7		20	17.5	94	82.5
Sleep (in Hrs.)	<6	132	19.44	37	28	95	72	0.617	23	17.4	109	82.6	0.38
	6–8	407	59.94	100	24.6	307	75.4		52	12.8	355	87.2
	>8	140	20.62	39	27.9	101	72.1		18	12.9	122	87.1
Sleep Quality	Poor	77	11.34	27	35.1	50	64.9	0.097	18	23.4	59	76.6	0.009
	Adequate	407	59.94	96	23.6	311	76.4		57	14	350	86
	Excessive	195	28.72	53	27.2	142	72.8		18	9.2	177	90.8
Sleep Satisfaction	Yes	526	77.47	121	23	405	77	0.001	59	11.2	467	88.8	0.000
	No	153	22.53	55	35.9	98	64.1		34	22.2	119	77.8
Relationship Status	No	582	85.71	132	22.7	450	77.3	0	73	12.5	509	87.5	0.03
	Yes	97	14.29	44	45.4	53	54.6		20	20.6	77	79.4
Physical Exercise	No	145	21.35	43	29.7	102	70.3	0.247	23	15.9	122	84.1	0.39
	Yes	534	78.65	133	24.9	401	75.1		70	13.1	464	86.9
Physical Activity	Exercise/Yoga	166	24.45	46	27.7	120	72.3	0.545	22	13.3	144	86.7	0.85
	Play and Others	513	75.55	130	25.3	383	74.7		71	13.8	442	86.2
Smoking	No	671	98.82	172	25.6	499	74.4	0.118	93	13.9	578	86.1	0.26
	Yes	8	1.18	4	50	4	50		0	0	8	100
Tobacco	No	676	99.56	174	25.7	502	74.3	0.106	93	13.8	583	86.2	0.49
	Yes	3	0.44	2	66.7	1	33.3		0	0	3	100
Addiction	No	552	81.29	144	26.1	408	73.9	0.836	69	12.5	483	87.5	0.06
	Yes	127	18.71	32	25.2	95	74.8		24	18.9	103	81.1
Anxiety	Yes	93	13.70	54	58.1	39	41.9	0.00	-	-	-	-	-
	No	586	86.30	122	20.8	464	79.2		_-	-	-	-	-
Depression	Yes	176	25.92	-	-	-	-	-	54	30.7	122	69.3	0.00
	No	503	74.08	-	-	-	-	-	39	7.8	464	92.2

*Positive depression indicates PHQ-4 score (Sum of Q.1and 2) more than or equal to 3. ^#Positive anxiety indicates PHQ-4 score (Sum of Q.3and 4) more than or equal to 3

Figure 2.

Showing overall distributions of participants

The proportion of depression was higher in adolescents aged 16-19 years (35.8%) and 13-15 years (24.8%) as compared to 10–12 years (23.5%). Similarly, males had a higher prevalence (28% vs. 23.2%) than females. Higher prevalence of depression was reported in participants in higher secondary grade vs. secondary grade (37.8% vs. 23%), those having lower and middle SES (33.3% and 24.7%) as compared to upper SES (20.6%), Those with unsatisfactory sleep vs. those with satisfactory sleep (35.9% vs. 23%), Poor sleep and excessive sleep (35.1% and 27.2%) as compared to adequate sleep (23.6%), those engaged in a relationship and not in a relationship (45.4% vs. 22.7%), Smokers and non-smokers (50% vs. 25.6%), Tobacco users vs. non-users (66.7% vs. 25.7%), those with anxiety and those without anxiety (58.1% vs. 20.8%), Those do not perform physical exercise vs. those who perform (29.7% vs. 24.9%) [Table 1 and Figure 3].

Figure 3.

Showing associated risk factors of anxiety and depression

Similarly, the proportion of anxiety found higher in adolescents aged 16–19 years and 13–15 years (22.1% and 15.5%) as compared to 10–12 years (6.9%), in Higher secondary grade vs. secondary grade (23.3% vs. 8.5%), Those with unsatisfactory sleep vs. those with satisfactory sleep (22.2% vs. 11.2%), those with poor sleep (23.4%) as compared to adequate or excessive sleep (14% and 9.2%), Those engaged in a relationship vs. not in a relationship (20.6% vs. 12.5%), Those with some addiction vs. without addiction (18.9% vs. 12.5%), Those do not perform physical exercise vs. those who perform (15.9% vs. 13.1%), Those with depression vs. those without depression (30.7% vs. 7.8%). The proportion of anxiety was slightly higher in males than in females (15.4% vs. 12.4%, P = 0.273), also not significantly different by SES (17.5% vs. 14.7%) [Table 1 and Figure 3].

The results of odds ratio are presented in [Table 2]. According to Odds ratio, being older, having higher secondary grades, and not having sleep satisfaction are significantly associated with depression and anxiety. [Figure 4] Anxiety is associated with late adolescence, higher secondary grades, unsatisfactory and poor sleep, addiction, not performing physical exercise, and depression. The risk of depression was found high among students aged (16-19) (OR: 1.81,95%CI: 1.07–3.06), in lower SES (OR: 1.55, 95%CI: 1.0–2.39), among those from higher education class (OR: 1.79,95%CI: 1.27–2.53), among those unsatisfied with sleep (OR: 1.88, 95%CI: 1.28–2.77), in relationship (OR: 2.83,95%CI: 1.82–4.41), and having anxiety (OR: 1.33,95%CI: 1.20–1.47). The risk of anxiety was found significantly high in students aged above 12 years. The adolescents from higher education class (OR: 2.38,95%CI: 1.54–3.70), who do not have satisfactory sleep (OR: 2.26, 95%CI: 1.42–3.61), are in a relationship (OR: 1.81,95%CI: 1.05–3.14) and those smoke (OR: 0.86,95%CI: 0.84–0.89) had higher anxiety. The adolescents who experienced depression also had high anxiety (OR: 1.889, 95%CI: 1.48–2.41).

Table 2.

Risk factors associated with depression and anxiety among adolescents

Domain	Variables	Depression			Anxiety
		OR*	(95% CI)#	P	OR	(95% CI)	P
Age (ref. 10-12 years)	13-15	1.07	(0.72–1.59)	0.57	2.48	(1.37–4.49)	<0.001
	16-19	1.81	(1.07–3.06)		3.82	(1.87–7.81)
Sex (ref. male)	Female	0.78	(0.55–1.11)	0.16	1.28	(0.82–1.98)	0.27
Class (ref. Below 10th)	Above 10th	1.79	(1.27–2.53)	0.018	2.38	(1.54–3.70)	0.001
SES (ref. upper-middle)	Lower	1.55	(1.002–2.39)	0.12	1.43	(0.83–2.47)	0.40
Sleep (in Hrs.) (ref. Abnormal)	Normal (6-8)	0.84	(0.59–1.19)	0.62	0.83	(0.53–1.28)	0.38
Sleep Quality (ref. Poor)	Adequate/Excessive	0.61	(0.37–1.008)	0.097	0.47	(0.26–0.83)	0.009
Sleep Satisfaction (ref. Yes)	No	1.88	(1.28–2.77)	0.001	2.26	(1.42–3.61)	0.000
Relationship Status (ref. No)	Yes	2.83	(1.82–4.41)	0.00	1.81	(1.05–3.14)	0.03
Physical Exercise (ref. Yes)	No	1.19	(0.89–1.59)	0.25	1.2	(0.78–1.87)	0.39
Smoking (ref. No)	Yes	2.90	(0.72–11.73)	0.12	0.86	(0.84–0.89)	0.257
Tobacco (ref. No)	Yes	5.77	(0.52–64.03)	0.11	0.86	(0.84–0.89)	0.489
Addiction (ref. No)	Yes	0.95	(0.61–1.49)	0.84	1.63	(0.98–2.72)	0.059
Anxiety (ref. No)	Yes	1.889	(1.48–2.41)	0.000	-	-
Depression (ref. No)	Yes	-	-	-	1.33	(1.20–1.47)	0.000

*OR: Odd’s Ratio, ^#CI: Confidence Interval

Figure 4.

Showing common risk factors of anxiety and depression

Multivariable analyses with all significant associated factors from univariable analyses were entered together during logistic regression. The accurate prediction of depression and anxiety in the logistic regression method was 76.3% and 86.3%respectively. The results of logistic regression (multivariate analyses) are presented in Table 3. Based on Multivariate analyses, higher education level (AOR: 1.53, 95%CI: 1.06–2.20) and anxiety (AOR: 4.88, 95%CI: 3.07–7.76) were associated with depression. Anxiety was associated with increasing age (16–19 years) (AOR: 3.35, 95%CI: 1.59–7.06) and depression (AOR: 5.18, 95%CI: 3.26–8.25). The participants belonging to the higher education class (above 10^th) are 1.53 times more likely to develop depression as compared to those belonging to the class below 10^th. Also, the participants aged 16–19 years are 3.35 times more likely to be anxious as compared to the lower age group. Anxiety and depression are strongly associated with each other [Table 3].

Table 3.

Regression analyses of factors associated with depression and anxiety among adolescents

Domain	Variables	Depression			Anxiety
		AOR$	(95% CI)#	P	AOR	(95% CI)	P
Age (ref. 10-12 years)	13–15	-	-	-	2.58	(1.39–4.77)	0.003
	16–19	-	-	-	3.35	(1.59–7.06)	0.001
Class (ref. Below 10th)	Above 10th	1.53	(1.06–2.20)	0.02	-	-	-
Anxiety (ref. No)	Yes	4.88	(3.07–7.76)	0.000	-	-	-
Depression (ref. No)	Yes	-	-	-	5.18	(3.26–8.25)	0.000

^$AOR: Adjusted Odd’s Ratio, ^#CI: Confidence Interval

Discussion

Prevalence of depression and anxiety

Although wide variations (3.7%–65%) in the prevalence of depression have been noticed among adolescents in India, all are aggregating to approximately 40%.[19,25,26,27,28,29,30,31,32,33,34,35,36,37,38] High prevalence of depression among adolescents was found in Tamil Nadu, Kerala, and Goa,[39] and also in Noida (38%),[25] Chandigarh (40%),[26] Mangalore, south India (40.8% and 49%),[27,28] Delhi, north India (47.9%),[19] Bihar (49.2%)[29] Patna (51.2%),[30] Rohtak, north India (52.9%),[31] Kerala, south India (57.7%)[32] Davangere south India (57.7%),[33] Raipur (59.9%),[34] Chennai (60.8%),[35] Karnataka (62.6%),[31] Chandigarh, (65.53%),[36] Mangalore (68%),[37] and Bhopal, Madhya Pradesh (71.3%),[38] Tamil Nadu, South India (73.6%),[40] However, Lower prevalence is reported from Uttar Pradesh, north India (14.5%),[41] Pune, western India (18.4%),[42] Haryana (20.6%),[43] and Tamil Nadu, south India (25%).[31]

Similar findings from earlier studies revealed that the pooled prevalence of anxiety ranged from 23% to 41%.[44] Eastern Uttar Pradesh (15%),[41] Ballabhgarh, Northern India (22.7%),[45] Kerala (25.8%),[46] Union Territory of India (36%),[47] Tiruchirappalli, South India (51%),[48] Mangaluru, south India (54.7%),[27] Maharashtra (60%),[49] Delhi, north India (65.3%),[28] and multicenter study at schools of six India states (66%)[50] are studies that reported higher prevalence of anxiety than (13.70%) in the present study. The prevalence of depression and anxiety across all these studies varies due to various reasons. Using different screening tools for measurement could be one of the most likely causes. Additionally, differing prevalence rates are caused by variations in socio-demographic profiles, age groups, time periods, and other relevant aspects. It has been shown that structured instruments and multi-stage diagnostic methods have reported relatively lower point prevalence rates ranging from 2.33% to 25%.[51,52,53,54,55,56]

However, studies that simply use screening tools have a propensity to over-report the point frequency.[57] The point prevalence range of studies about school-going adolescents from India is broader and more varied when compared to data from other countries.[58] Across the countries, the prevalence of depression and anxiety among adolescents varies in a wide range [Table 4].

Table 4.

Prevalence of Depression and Anxiety among adolescents in different countries

Countries	Depression (in %)	Anxiety (in %)
USA[59]	11.7	31.9
Pakistan[60]	17.2	21.4
Bhutan[61]	14.3	9
Bangladesh[62]	26.5	18.1
Sri Lanka[63]	36	28
Present Study	25.92	13.70

Associations with depression and anxiety

Significant associated factors for depression included being male, having a higher secondary grade, having a low SES, having unsatisfactory and poor sleep, smoking and using tobacco, not being involved in physical activity, and having anxiety. Significant associated factors for anxiety included being older, having higher secondary grades, poor sleep quality, unsatisfactory sleep, having depression.

In contrast to earlier studies, the present study found that depression is more prevalent in the 13-15 age range (middle adolescence) Similar to previous studies, Anxiety is more common among 16–19 years of age group.[41] Previous studies have shown a statistically significant association of depression with older or late adolescents (above 15 years).[19,28,30,31,33,35,39,41,43,64] Another study found no association between age and prevalence of depression.[27] Depression is more common in males (28%) compared to females (23.2%) similar to previous studies.[31,33] However, one study has shown no similar correlation between sex and the prevalence of depression.[57] Contrary to this, other studies revealed that it is higher in females.[19,27,28,29,30,32,35,36,38,39,41,43,64] Unlike depression, anxiety is more common in females in the present study. Similar findings from earlier studies have also been demonstrated.[19,41,45,48,65,66,67] Contrarily, one study revealed that males are more affected by anxiety and depressive states.[68] Both Depression and anxiety are more common among higher secondary class (11-12^th) students in the present study. These findings are comparable with previous studies showing higher prevalence among the 9^th to 12^th class.[19,30] No comparable associations were also observed in some studies.[26,35,41,69] In the present study, lower SES groups had higher rates of depression and anxiety. A single study revealed that those in higher SES groups are more likely to experience depression.[64] Similar to this, adolescents from lower-middle SES had twice as much anxiety as those from upper SES.[41,45,48,68] It has also been observed that there is no significant difference between anxiety and depression when socio-demographic characteristics are taken into account.[31,48] As per severity, no depression was found in 62.3%, which is higher than the previous studies.[31,64] Comparatively, mild depression (26.07%) and moderate depression (8.98%) are substantially lower than the earlier studies.[19,28,30,31,43,64] Severe depression was observed in 2.65% of participants, which is higher than previous studies[28,43] but lower than two recent studies.[19,31] Moderate anxiety is more prevalent in previous studies.[19]

Depression and anxiety are more prevalent as age advances; the most likely explanation is that with an increase in age, the understanding of the symptoms in a child also increases, resulting in better reporting of their emotional states. The exact causes of gender disparities are also unknown, but post-pubertal onset combined with a variety of biological factors, hormonal variables, and social factors may be the probable reason.[43,70] Along with other pubertal characteristics, Increase in education level may also influences the personality of a child.[41] This may be due to pressure placed on students to achieve well academically in the board exams.[36,71] According to a prior study, other associated factors like sleeping fewer than six hours, unsatisfactory sleep, being in a relationship, no physical activity, and smoking are associated with depression.[19] Depression in adolescents was found to be substantially correlated with physical activity. It has been observed that there is a direct association of depressive symptoms with adolescents’ physical activity.[72] Other associated risk factors like substance abuse, poverty, and social instability prevalent in other countries are also associated with anxiety and depression in India, resulting in comparable prevalent data.[73,74] Taken together, these findings imply the necessity of concentrating on depression and anxiety in children and adolescents. To effectively reach adolescents, a multi-level approach using a variety of delivery platforms and tactics is needed.

WHO is focussing on the promotion, prevention, and provision of mental health care for children, adolescents, and their families through various multi-sectoral evidence-based strategies. A module on Child and Adolescent Mental and Behavioural Disorders was developed as part of the mhGAP Intervention Guide 2.0. Also, Helping Adolescents Thrive (HAT), and Helping Adolescents Thrive (HAT) is a joint Initiative by WHO-UNICEF, are some of the steps taken by WHO to strengthen policies and programs for adolescent mental health. The significance of adolescents’ mental health needs to be emphasized in India as well. To improve the current situation in the nation, several steps have already been taken, including the right to mental health care in the new Mental Healthcare Act, the vision in the National Mental Health Policy, and the inclusion of mental health services in the rules of the Health and Wellness Centres (as part of the Ayushman Bharat Yojana or the National Health Protection Scheme).

Strengths of the study

The present study reports the burden of depression and anxiety disorders among adolescents in Delhi, India. The associated socio-demographic factors are also shown which can help manage adolescents for the future. The present study has been prepared by the STROBE guidelines.[75]

Limitations of the study

The present study should be interpreted in the light of several limitations. This study has been conducted on urban school-going adolescents. Comparative data from rural school-going adolescents is yet to be considered. Because the study relied on self-reporting, well-known issues including memory recall dependency and social desirability may have tainted their reporting. The study was cross-sectional prospective observations may give better results but is time-consuming.

Future directions of the study

A multi-centric study with larger samples that includes adolescents from different states and vast rural areas of India should be taken into consideration. It is also necessary to perform community studies or long-term longitudinal studies to pinpoint and comprehend the risk variables involved. Children under the age of 10 years should also be the focus of future research to spot any early mental health issues. Further research should also take into account comparable rural school-going adolescents. It is also possible to study a high-risk sample of siblings and children of people who have significant mental illnesses like depression and anxiety.

Conclusions

The present study has shown the updated picture of the prevalence of depression and anxiety among adolescents in Delhi, India. This attempt is a try to collate the information regarding the magnitude of associated factors, risk factors, and other relevant factors related to the condition. Every adolescent has a right to mental health, according to the WHO. It is imperative to attend to the needs of adolescents with mental health issues. The consequences of failing to address these need extend to adulthood, impairing both physical and mental health and limiting opportunities to lead fulfilling lives as adults. Effective interventions like reducing psychological burden, career counseling, and making learning more interesting may be devised to alleviate the considerable burden of depression and anxiety among adolescents in India. This information may also contribute to the development of preventive and control strategies for mental health conditions among adolescents, on a national platform for the welfare of the adolescents.

Institutional ethical committee

All India Institute of Ayurveda, IEC-AIIA/2021-P81.

Statement for ethics

All authors undertake that the manuscript being submitted to this journal has not been submitted, accepted or published to any other journal.

Authors contribution

Conceptualization: Mahapatra Arun Kumar (MAK), Rajagopala S (RS), Sonam (S),

Data Curation: S, Rishabh (R)

Formal analysis: MAK, Anil Kumar (AK), Prashant Kumar Gupta (PKG)

Investigation (Data Collection): S and R

Methodology: MAK, RS, S, Shahzadi Malhotra (SM)

Project Administration: S

Resources: S and R

Supervision: MAK, RS, Tanuja Manoj Nesari (TMN), SM

Validation: MAK, AK, TMN, SM

Visualization: S

Writing-original Draft: S

Writing-review and Editing: MAK, RS, AK, PKG, TMN, SM.

Conflicts of interest

There are no conflicts of interest.

Supporting Information: Annexure 1. Self-reported Questionnaire

Survey Questionnaire (English Version)

Section A: Socio-Demographic Information

SI No	Questions	Answers/coding
A.1	Age (in Years)
A.2	Sex	1. Male	2. Female
A.3	Religion	1. Hindu	2. Muslim
		3. Sikh	4. Christian
		5. Others
A.4	Education/Class	1. Class 12	2. Class 11
		3. Class 10	4. Class 9
		5. Class 8	6. <8th
A.5	Type of School	1. Govt.	2. Semi-Govt. 3.Private
A.6	Education of Father	1. Illiterate	2. Primary School Certificate (5th )
		3. Middle School Certificate (8th)	4. High School Certificate (10th)
		5. Intermediate or diploma (12th)	6. Graduate
		7. Profession or Honours
A.7	Education of Mother	1. Illiterate	2. Primary School Certificate (5th)
		3. Middle School Certificate (8th)	4. High School Certificate (10th)
		5. Intermediate or diploma (12th)
		6. Graduate
		7. Profession or Honours
A.8	Occupation of Father	1. Legislators, Senior Officials and Managers
		2. Professionals
		3. Technicians and Associate professionals
		4. Clerks
		5. Skilled Workers and Shop and Market Sales Workers
		6. Skilled Agricultural and Fishery Workers
		7. Craft and Related Trade Workers
		8. Plant and Machine Operators and Assemblers
		9. Elementary Occupation
		10. Unemployed
A.9	Occupation of Mother	1. Legislators, Senior Officials and Managers
		2. Professionals
		3. Technicians and Associate professionals
		4. Clerks
		5. Skilled Workers and Shop and Market Sales Workers
		6. Skilled Agricultural and Fishery Workers
		7. Craft and Related Trade Workers
		8. Plant and Machine Operators and Assemblers
		9. Elementary Occupation
		10. Unemployed
A.10	Total Monthly Family Income (in Rs.):	1. Rs. ≥1, 23,300	2. Rs. 61,600-123,300
		3. Rs 46,100-61,600	4. Rs. 30,800-46,100
		5. Rs 18,500-30,800	6. Rs. 6,100-18,500
		7. Rs ≤6100
A.11	Socio-eco. Status	1. Upper (I)	2. Upper-Middle (II)
		3. Lower-Middle (III)	4. Upper-Lower (IV)
		5. Lower (V)
A.12	Height (in cm)
A.13	Weight (in Kg)

Section B: Mental Health Assessment

Over the last 2 weeks, how often have you been bothered by the following problems? PHQ-4
SI No	Questions	Answers/coding
B.1.1	Feeling nervous, anxious or on edge	0=Not at all
		1=Several days
		2=Over half the days
		3=Nearly every day
B.1.2	Not being able to stop or control worrying	0=Not at all
		1=Several days
		2=Over half the days
		3=Nearly every day
B.1.3	Little interest or pleasure in doing things	0=Not at all
		1=Several days
		2=Over half the days
		3=Nearly every day
B.1.4	Feeling down, depressed, or hopeless	0=Not at all
		1=Several days
		2=Over half the days
		3=Nearly every day

Section C: Social Factors

SI No	Questions	Answers/coding
C.1	Birth Order	1. First (1st)	2. Second (2nd)
		3. Third (3rd)	4. >3rd
C.2	Type of Family	1. Nuclear	2. Joint
C.3	No. of family members	1. <4	2. Four to Five (4-5)
		3. >5
C.4	Residence	1. Urban	2. Semi-Urban
		3 Rural
C.5	Type of House	1. Pakka	2. Kachcha
C.6	Source of drinking water	1. RO	2. Govt. Supply
		3. Hand-pump	4. Others
C.7	Toilet facility	1. Private	2. Public
		3 Open-Toilet
C.8	Domestic/Pet animals	1. Absent	2. Present
C.9	Living with whom	1. With Family	2. Apart from Family
C.10	Are you in a Relationship	1. No	2. Yes
C.10.1	Duration	__________Months/Years
C.11	Relationship with your Siblings	1. Very Good	2. Good
		3. Not Good Not Bad	4. Bad
		5. Very Bad
C.12	Relationship with your classmates	1. Very Good	2. Good
		3. Not Good Not Bad	4. Bad
		5. Very Bad

Section D: Lifestyle related Factors

SI No	Questions	Answers/coding
D.1	How often you eat fruits in a week?	1. Never	2. Once
		3. Twice	4. More than 3 times
D.2	How often you eat vegetables like spinach, pumpkin, cauliflower, ladyfinger etc.in a week in your diet?	1. Never	2. Once
		3. Twice	4. More than 3 times
D.3	How often you drink carbonated soft drink, such as Coke, Pepsi, and Fanta etc., in a week?	1. Never	2. Once
		3. Twice	4. More than 3 times
D.4	How often you eat fast foods such as Burger, Pizza, French fries, Tikki etc., in a week?	1. Never	2. Once
		3. Twice	4. More than 3 times
D.5	How many hours you spend to watch TV per day?	1. Never	2. Less than 1 Hour
		3. 1-2 Hours	4. More than 2 Hours
D.6	How many hours you spend on Mobile phones?	1. Never	2. Less than 1 Hour
		3. One-two Hours	4. More than 2 Hours
D.7	Do you use internet?	1. Yes	2. No
D.7.1	Duration	1. Less than 1 Hour	2. One-Three Hours
		3. More than 3 Hours
D.8	What are your main uses of internet?	1. Education and E-learning
		2. Playing games
		3. Social Media & E-mail
		4. Whatsapp/Instagram/Facebook
		5. Others
D.9	Do you perform any physical exercise daily?	1. No	2. Yes
D.9.1	Frequency	1. Regularly	2. Irregularly
D.9.2	Duration	1. Less than 15 min.	2. 15-30 min
		3. 30-60 min.	4. More than 60 min./1 hr
D.10	Which Physical activity do you like most?	1. Playing games	2. Exercise
		3. Yoga	4. Others
D.11	Do you go for tuition?	1. No	2. Yes
D.11.1	Duration	__________Hours/day
D.12	How much time do you spend on studies other than school and tuition hours?	1. No	2. Less than 1 Hour
		3. One-Two Hours	4. More than 2 Hours
D.13	On average, how many hours did you sleep during night in past 7 days?	1.Less than 6Hours	2. 6-8Hours
		3. More than 8 Hours
		_____________Hours/Night
D.14	Sleep Quality	1.Poor	2.Adequate
		3.Excessive
D.15	Are you satisfied with the sleep quality of your past 7 nights?	1. Yes	2. No
D.16	Do you smoke cigarette/Beedi currently?	1. No	2. Yes
D.16.1	Duration (Since how long)	________Days/Months
D.16.2	Frequency (No. of Cigarette/Beedis per day)
D.17	Do you consume Tobacco/Gutkha/Paan etc., currently?	1. No	2. Yes
D.17.1	Duration (Since how long)	________Days/Months
D.17.2	Frequency (No. Packets per day)
D.18	Which subject do you like the most/interesting subject? And Why?
D.19	Which subject do you dislike the most/Boring/Uninteresting subject? And Why?

Section E: Personal History

SI No	Questions	Answers/coding
E.1	Type of Diet	1. Veg.	2. Mixed
E.2	Appetite	1. Good	2. Average	3. Poor
E.3	Bowel habits	1. Regular	2. Irregular
E.4	Bladder habits	1. Regular	2. Irregular
E.5	Thirst	1. Normal	2. Less	3. Excessive
E.6	In your opinion, how would you rate your General Health?	1. Good	2. Moderate	3. Poor
E.7	In your opinion, how would you rate your Personal Hygiene?	1. Good	2. Moderate	3. Poor
E.8	Addiction

Funding Statement

Nil.