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. 2021 Sep 21;12:110. doi: 10.4103/ijpvm.IJPVM_312_19

Prevalence of Depression in Iranian School Students: A Systematic Review and Meta-Analysis

Abbasali Karimi 1, Nourollah Yadegari 1, Diana Sarokhani 2, Moloud Fakhri 3*,✉, Ali Hasanpour Dehkordi 4*,✉
PMCID: PMC8551795  PMID: 34760121

Abstract

Background:

Depression is one of the major psychiatric disorders in the world. The present study was conducted to determine the prevalence of depression among Iranian school students through a meta-analysis.

Methods:

All national and international information databases including PubMed, Scopus, Web of Science, SID, Magiran, Medlib were searched. The search phase was performed without language and time restrictions, but the searched studies were all in Persian and English, and the sources were updated by 03.08.2020. As the selected studies had high heterogeneity, the random effects model was used.

Results:

In 51 studies with a sample of 537144 people, the prevalence of depression in Iranian school students was 37% (95%CI: 32, 42). In addition, the prevalence of depression in girl school students was 45% (95%CI: 25-65) and in boys was 28% (95%CI: 20-35). The prevalence of mild, moderate and severe depression in school students is 31%, 18% and 11%, respectively. Also, the prevalence of depression in primary school students was 12%, middle school students 32%, high school students 47% and pre-university students 46%.

Conclusions:

About a third of Iranian school students suffer from some degree of depression, and the prevalence of depression in girls is about twice that of boys. The prevalence of mild depression among school students is higher than moderate and severe depression. On the other hand, the prevalence of depression in school students from primary to pre-university level is increasing, which is very worrying.

Keywords: Depression, Iran, prevalence, school students

Introduction

Depression is a serious disorder that affects all aspects of quality of life and leads to economic, social, occupational, and familial problems in affected individuals.[1,2] World Health Organization identifies depression as the fourth cause of disability in the world and predicts that it will be the second leading cause of disability in the world by 2020.[3] Depression is a disorder characterized by a decrease in energy and interest, feeling guilty,[4] difficulty concentrating, inferiority, and thoughts of death and suicide, and is associated with a change in the level of activity, cognitive abilities, speech, sleep, appetite, and other biological rhythms.[5]

The prevalence of depression in children and adolescents is a topic that needs serious attention because of impairment in various social, educational, professional and other functions.[6] Depression in adolescence is a growing psychological problem that can cause educational and academic failure, physical and social problems, and therefore may alter the future of adolescents.[7,8] Depression may aggravate the accompanied chronic diseases such as diabetes, renal failure, and hypertension.[9,10] Several factors can contribute to depression, such as age, sex, educational background, type of school, academic performance, household size, birth rank, occupation and parental education, residence status, history of mental disorders in parents, and family structure[11] and in this regard poor mental and educational performance, weakening of role play, increasing paradox with parents and suicidal thoughts or suicide attempts are the consequences of depression.[12] Depression may lead to obesity and presenting the diabetes and hypertension by itself too[13]. Additionally, depression can predispose the individuals to cardiovascular disease and decreasing the immune system potency and even cancers.[14,15]

Iran is a young country, of which more than half of the population is people under the age of 18 years. In this regard, it is important to study the problems and solve them among adolescent students as future community managers, who account for 25% of the population of the country.[11,16]

Prevalence of depression in students in Rostamzadeh study in Urmia based on Beck questionnaire 68%,[17] in Shojaeizadeh study in Kazerun using zong questionnaire 42%,[18] and in Shakibaei study in Isfahan with questionnaire CDI was reported 22%.[19]

In Iran, many studies have examined the prevalence of depression in school students, and these studies have reported different findings, the need for a meta-analysis study seems necessary to provide us a comprehensive and accurate estimate of the prevalence of depression in Iranian school students. Therefore, the present systematic and meta-analytic study was conducted to determine the prevalence of depression in Iranian school students.

Methods

Study protocol

The present study used systematic review and meta-analysis methods.

Statistical population

Participants in the selected studies were school students with no limitations gender.

Studied results

Primary results

Estimation of the prevalence of depression in Iranian school students by different questionnaires such as: Beck, SCL-90, Zong, and etc.

Secondary results

Estimation of the prevalence of depression in Iranian school students by sex, and depression level (mild, moderate and severe) in Iranian school students.

Search strategy

The present study is a meta-analysis study for determining the prevalence of depression among Iranian school students. international and national database PubMed, Scopus, Web of Science, SID, Magiran, Medlib were deeply searched using valid keywords of “Prevalence, Depression, School students, and Iran “and Latin and their combinations using the (AND, OR) operators. The documents found were published from 1998 to 2019. The search phase was performed without language and time restrictions, but the searched studies were all in Persian and English, and the sources were updated by 03.08.2020. In order to find articles that were not found during the e-search phase, the sources of the available articles were reviewed and thus a manual search was performed, but no new article was found.two researchers independently searched the databases.

Search strategy in PubMed

(((Iran [Affiliation]) AND (Prevalence)) AND (Depression OR Depressive Symptom OR Emotional Depressions)) AND (School Enrollment OR School students)

Inclusion and exclusion criteria

Studies that examined the prevalence of depression in Iranian school students were included and the age group of the study participants was over 5 years old. The exclusion criteria were non-Iranian studies, non-random sample size studies, failure to report required information such as the sample size or the prevalence of general depression or its levels in school students, Our statistical population was healthy individuals and school students who had mental health problems were not included in the study, poor quality of studies according to STROBE1 checklist[17] and the inaccessibility of full text of studies.

Qualitative assessment of studies

The standard and international STROBE checklist was used to assess the quality of the studies. The checklist consists of 22 different sections. In this regard, 51 papers that received at least a score of 16 from the checklist were entered into the meta-analysis process.

Data extraction

In this study, two researcher independently extracted data from studies to minimize reporting bias and error in data collection. The researchers entered the extracted data in a checklist containing: name of author, study title, year of study, city of study, prevalence of depression in boy and girl school students, name of questionnaire, mean age, degree, the severity of depression as mild, moderate and severe, sample size, and the number of girls and boys separately. The third researcher then examined the data extracted by the two previous researchers, so that if there were inconsistencies in both files, it would be reviewed and resolved.

Questionnaires

The Beck Depression Inventory (BDI)2: The Beck questionnaire is a self-report questioner includes 21 items that assess the severity of depression symptoms in emotional, cognitive and physical aspects. Each question had a set of at least four possible response ranting in intensity, a value of 0 to 3 is assigned for each answer. Total score range from 0 to 63. Higher total scores indicate more severe depression symptoms.[18]

The Symptom Checklist-90 (SCL-90-R)3:

The SCL-90-R is normed on individuals 13 years and older. It consists of 90 items and takes 12–15 minutes to complete. It shows nine dimension of symptoms including; somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, psychoticism. It consist of a category of “additional items” which helps clinicians assess other aspect of the clients symptoms.[19]

Children Depression Inventory (CDI)4: The Child Depression Inventory is a psychological assessment that shows the severity of depressive symptoms in children and adolescents. This scale has 27 items that are classified into 5 main areas and each question is assigned a score from 0 to 2. Therefore, the overall scoring varies between 0 and 54.[20]

Rutter5: the Rutter Children's Behavior Questionnaire (1967) is a 26- item survey designed to evaluate children's behaviors at school. It completes by teachers. Answers are rated on a scale of 0 to 2, with higher ratings indicating more severe presence of the symptoms. Possible ratings on the scale range from 0 to 52.[21]

Depression, Anxiety and Stress Scale -21 Items (DASS-21)6: The scale has 21 questions, of which 7 are related to depression, 7 to anxiety and 7 to stress assessment. Each question is scored from 0 to 3 and the whole questionnaire is scored from 0 to 63.[22]

And other questionnaires such as

SDS, CES-DC, K-SADS, TRF, DSM-IV, Zong, GSHS, CADS, GHQ-28.

Statistical analysis

A random effects model was used to pooled the results of studies. I2 test was used to evaluate the heterogeneity of studies. Subgroup analysis were done according to the questionnaire type, gender, level of education, level of depression (mild, moderate and sever). The Egger test and funnel plot were used to checked publication bias. Meta-regression was used to investigate the relationship between the year of publication of studies, sample size of studies with the prevalence of depression in school students. Sensitivity analysis was used to investigate influence studies. STATA Ver. 14 was used for data analysis.

Results

In this meta-analysis, 51 articles with a sample of 537144 people were reviewed. The data of the articles reviewed are summarized in Table 1 and the stages of the entry of studies into the meta-analysis process are presented in Figure 1. The results of meta-analysis on the prevalence of depression in Iranian school students based on different Subgroups are shown in Table 2.

Table 1.

Information of the articles entered into the meta-analysis process

Author Year of Study City of Study Mean Age (year) Degree of school students Name of Questionnaire Prevalence of Depression (%) Sample Size Number of girls Number of boys Prevalence of depression in girls Prevalence of depression in boys
Sooky Z[23] 2010 Kashan 14-17 High school Beck 53.5 762 762 - - -
Monir poor N[24] 2005 Rey 14-18 High school Beck - 388 222 166 - -
Rostamzadeh Z[25] 2007 Urmia 14-18 High school Beck 68.1 2023 - - - -
Anvari S[20] 2009 Bam 14-18 High school Beck 74.2 472 306 166 - -
Riasi HR[26] 2012 Birjand 14-18 High school Beck 51 200 96 104 55.2 48.1
Zahirodin A[22] 2004 Firuzkooh 14-18 High school Beck - 604 296 308 73 58
Mahmudnia A[27] 2011 Gharchak 14-18 High school Beck - 475 - - - -
Rahimian E[28] 2008 Shahreza 12-18 Secondary school and High school Beck - 960 - - - -
Narimani M[29] 2002 Ardebil 14-18 High school Beck - 197 197 - - -
Toulabi T[30] 2014 KhorramAbad 14-19 High school Beck - 152 - - - -
Roshan R[31] 2002 Ardebil 14-18 High school Beck - 967 - - - -
Rezaei-Barmi M[32] 2011 Karaj 14-18 High school Beck - 160 - - - -
Modabber Nia MJ[33] 2007 Rasht 14-20 High school Beck 33.9 3681 - - - -
Shojaeizadeh D[34] 2001 Kazeron - Pre university Zong 42.9 240 - 240 - -
Turi A[35] 2015 Birjand - High school DASS-21 27.5 400 200 200 - -
Jahangasht Kh[36] 2016 Rasht - Secondary School CDI 10 753 398 355 11.3 8.5
Nejati V[37] 2012 Tehran 7-14 Elementary and Secondary school Rutter 4.2 347 - - - -
Haghbin S[38] 2003 Gachsaran& Yasouj 7 Elementary 1.2 2846 1446 1397 - -
Shahsavarani AM[39] 2013 Tehran 14-19 High school CADS 67.1 417 - - - -
Haji maghsoudi F[40] 2004 Bam 17-18 Pre university SCL-90-R 49.4 259 151 108 48.3 50.9
Khodakarami B[41] 2013 Hamedan 11-15 Secondary School Woodworth 49.5 400 400 - - -
Shakibaei[42] F 2014 Esfahan 11-16 Secondary School CDI 22 1606 803 803 24.2 19.8
Shakiba M[43] 2012 Zahedan - SCL-90 70 40 40 - - -
Musavi-bazaz SM[44] 2015 Bashagard 14-21 High school SCL-90 5.4 313 122 191 12.3 1
Shams G[45] 2011 Ardakan&Meibod 14-18 High school SCL-90 91.2 909 553 356 91.2 -
Azizi-soleiman F[46] 2016 - 6-18 Elementary, Secondary school and High school GSHS 21 11701 5823 5878 - -
Ahmadi J[47] 2014 Shiraz 6-18 Elementary, Secondary school and High school DSM-IV 3 1020 510 510 5 1
Ahadi Z[48] 2016 - 6-18 Elementary, Secondary school and High school GSHS - 13486 - - 22.8 19.1
Ghobari-bonab B[49] 2009 Tehran 6-12 Elementary TRF 2 1407 - - - -
Ahmadkhaniha H[50] 2002 Tehran 11 Elementary K-SADS 61.4 87 31 56 86.7 48.2
Hoseinifard SM[51] 2005 Rafsanjan 14-18 High school SCL-90 2.4 830 - - 3.1 1.6
Sadeghian E[52] 2010 Hamedan 16 High school GHQ-28 45.8 600 - - - -
Zargham-borojeni A[53] 2001 Esfahan 14-17 High school Beck 43.4 323 164 159 55.5 30.1
Hoseini SH[54] 2003 Rey 14 Secondary School SCL-90 41.1 350 - - - -
Sepehrmanesh Z[55] 2008 Kashan 17 High school SCL-90 18 400 - - - -
Moghrab M[56] 2010 Birjand - High school Beck 58.8 450 - - - -
Jena-abadi H[57] 2011 Saravan 14-19 High school SCL-90 - 125 - - - -
Ranjbar F[58] 2003 Tabriz 5-16 Elementary, Secondary school and High school Rutter 4.1 221 99 122 65.7 44.5
Habibpour Z[59] 2009 Esfahan 16-19 High school Zong - 400 - - - -
Rahimi-kian F[60] 2007 Karaj 13-18 High school Beck 64.8 264 - - - -
Rajabi Gh[61] 2004 Ahvaz 15 High school CDI 25.6 400 - - - -
Ghorbani B[62] 2006 Esfahan 8-16 Elementary, Secondary school and High school CDI 16.2 234 - - - -
Sayyari A[63] 2002 - 13 Secondary School 1.7 479504 - - - -
Abdollahian E[64] 2002 Mashhad 10-12 Elementary CDI 10.3 2071 1022 1049 13.1 7.6
Johari G[65] 1999 Ilam 17-18 High school Beck 29.1 372 - - 31 27
Shahnazi B[66] 2007 Tabriz 12-18 Secondary school and High school CES-DC 75.8 364 - - - -
Bahrami A[67] 2019 Mashhad& Sabzevar 12-18 Secondary school and High school Beck Beck 940 940 - - -
Safi-Al-Hosseini FS[68] 2018 Bojnurd 16.1 High school Beck Beck 384 384 - - -
Riahi F[69] 2017 Kuhdasht 15-18 High school Beck Beck 600 600 - - -
Servatyari K[70] 2019 Divandareh 16-19 High school Beck Beck 370 172 198 - -
Moeini B[71] 2019 Hamedan 15-18 Secondary School CES-D CES-D 670 - - - -
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Figure 1.

Figure 1

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Flowchart of the entry of studies into meta-analysis

Table 2.

The results of meta-analysis on the prevalence of depression in Iranian school students based on different Subgroups

Subgroups Number of study Prevalence of Depression (95% CI) I2 (%) P
Total Prevalence of Depression 40 37% (32-42) 99.9 <0.001
Total by Sex Prevalence of Depression in Girl 12 45% (25-65) 99.7 <0.001
Prevalence of Depression in boy 11 28% (20-35) 98.9 <0.001
Total by Level Prevalence of mild Depression 19 31% (25-37) 98.1 <0.001
Prevalence of moderate Depression 19 18% (13-23) 98.7 <0.001
Prevalence of severe Depression 18 11% (8-15) 99 <0.001
Total by Grade Prevalence of Depression in Elementary 4 12% (7-16) 99 <0.001
Prevalence of Depression in Guidance 6 32% (14-51) 99.8 <0.001
Prevalence of Depression in High school 19 47% (31-62) 99.8 <0.001
Prevalence of Depression in Pre university 2 46% (40-53) 53 0.145
Questionnaires Prevalence of Depression in Beck 12 %53 (43-63) 99.1 <0.001
Prevalence of Depression in SCL-90 7 %40 (5-74) 99.9 <0.001
Prevalence of Depression in CDI 5 %17 (%11-%23) 97 <0.001
Prevalence of Depression in Zong 1 %43 (37-49) --- ---
Prevalence of Depression in Rutter 2 %4 (3-6) 0 0.953
Prevalence of Depression in GSHS 1 %21 (20-22) --- ---
Prevalence of Depression in DASS-21 1 %28 (23-32) --- ---
Prevalence of Depression in CADS 1 %67 (63-72) --- ---
Prevalence of Depression in Woodworth 1 %50 (45-54) --- ---
Prevalence of Depression in DSM-IV 1 %3 (2-4) --- ---
Prevalence of Depression in TRF 1 %2 (1-3) --- ---
Prevalence of Depression in K-SADS 1 %61 (51-72) --- ---
Prevalence of Depression in GHQ-28 1 %46 (42-50) --- ---
Prevalence of Depression in CES-DC 1 %76 (71-80) --- ---
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According to Figure 2, there is no significant relationship between prevalence of depression in Iranian school students and the sample size (P = 0.159).

Figure 2.

Figure 2

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Relationship between prevalence of depression in Iranian school students and the sample size using the meta-regression model

This means that in larger studies (more samples), the prevalence of depression is lower in Iranian school students, but this decrease is not statistically significant.

According to Figure 3, there is no significant relationship between prevalence of depression in Iranian school students and year of study (P = 0.296).

Figure 3.

Figure 3

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Relationship between the prevalence of depression in Iranian school students and the year of the study using the meta-regression model

That is, over time and during the years 1997 to 2019, the prevalence of depression among Iranian school students has been upward. But this increase is not statistically significant.

Figure 4 shows that the prevalence of depression in Iranian school students is 37% (95%CI: 32%, 42%). The lowest prevalence of depression in school students was 1% (95%CI: 1%, 2%)[38] and the highest was 91% (95%CI: 89%, 93%)[45] [Figure 4].

Figure 4.

Figure 4

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Prevalence of depression in Iranian school students with a 95% confidence interval based on the type of questionnaires

In Figure 5 we see that the effect of diffusion bias is significant (P = 0.000). In the sensitivity analysis, we concluded that with the omission of the Shams study in 2011,[48] the prevalence of depression in school students will be reduced to 33% (95%CI: 29%, 37%) and in contrast to the omission of the Sayyari study in 1998[66] it will increase to 36% (95%CI: 29%, 43%). These two studies are, the most influence studies in the final result of the meta-analysis.

Figure 5.

Figure 5

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Publication bias prevalence of depression in Iranian school students

Discussion

In the study, which was conducted between 1997 and 2019, the prevalence of depression in school students was reported to vary from 1%[38] to 91%.[45] There are many reasons for these differences, including: different educational levels, type of schools (private or public), school students’ gender, economic and educational status of parents, variety of questionnaires, cultural differences in different cities and regions of Iran. The prevalence of depression was also different in different questionnaires. Due to the different types of questionnaires, differences in the cut-off score of each of them, different number of questions in the questionnaires, lack of uniform distribution of studies among different questionnaires, these differences have occurred.

With the exception of the Rutter questionnaire, the prevalence of depression was higher in girls than in boys. This shows that in the student body, girls are more vulnerable than boys, and since our girls today are the mothers of our country tomorrow and can play a significant role in society in the future as mothers and wives, mental health They should be paid more attention than before.

We could show no association between the prevalence of depression in Iranian school students and the number of research samples. In other words, with an increase in the sample size, the prevalence of depression in Iranian school students did not change significantly. Also, no relationship was found between the prevalence of depression in school students and research year and thus within the duration from 1998 to 2019, the prevalence of depression in Iranian school students has increased but this increase is not statistically significant.

In a meta-analysis study, the prevalence of depression in Iranian college students based on the Beck questionnaire was 40% (40% girls and 39% boys).[72] In another meta-analysis in 2013, the prevalence of depression in Iranian college students was 33%.[73] These studies show that the prevalence of depression in Iranian school students is more than college students. The study found that the incidence of depression in girls was almost two times compared to boys. This difference is likely to result from multiple biological, psychological, social and cognitive factors.

According to Gunilla Olssan study in 1999, the prevalence of depression among high school students in Sweden was 12.3%, which was 17.9% in girls and 6% in boys.[74]

Depression, anxiety and stress are the most common mental disorders of adolescence that threaten the health of the individual and society and are closely related to each other. In another study by Ehrenberg et al., on 366 high school students in Canada, the prevalence of depression using the Beck questionnaire was obtained to be 41.4%.[75]

According to a study by Ehrenberg et al., The prevalence of depression in high school students in Canada is lower than in Iran. In another study, the overall prevalence of depression based on the Beck questionnaire was 71.25%. This study showed that 46.3% of the depressed were female and 53.7% were male. 27.8% of students had mild depression, 29.3% moderate, 7.5% severe, and 6.7% very severe.[74] And the prevalence of depression in Iranian students was lower than Indian students. On the other hand, in the above study, the prevalence of depression in girls was lower than boys, which is not consistent with our study. In another study, in Canadian high school students. According to similar studies in the United Kingdom and the United States, 31.4% of the samples were clinically depressed, as measured by the Beck Depression Inventory.[73] The prevalence of depression was slightly higher in Iranian students than in Canadian students.

The rate of depression in Nigerian Students was 9%,[76] in Taiwanese students was in the range of 12.3% to 13.4%.[77] Similar studies have been conducted on depression in adolescents and high school students in other countries, with depression rate of 30% for Pakistani students.[78]

According to a study conducted by Slee et al. in Australia on pre-school students, the prevalence of depression was 33%.[79] The results of a study on 5423 high school students (sixth to eighth grades) in the United States showed the prevalence of major depressive disorder as 4.4%.[80]

As you can see, the prevalence of depression in Iranian students is higher than students in Nigeria, Taiwan, Australia, the United States and Pakistan.

Study limitations

The main limitations of the current study included the inability of the Iranian databases to combine the keywords, due to differences in the questionnaires, and distribution of number of studies in different regions of Iran (north, south, west and east) were not same.

Conclusions

Considering that about one third of Iranian students suffer from some degree of depression and the prevalence of depression in girls is about twice that of boys. Also, the prevalence of depression in students from primary to pre-university level is increasing and almost one third of Iranian students is anxious. Due to the fact that childhood and adolescence is one of the most critical periods in the life of each person due to psychological, intellectual and social changes that can affect his academic and professional performance. Therefore, the results of this study should be used by policy makers and mental health officials for proper planning to reduce mental disorders.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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