Prevalence and associated factor of depression symptoms among female secondary school students in Buraydah City, Saudi Arabia

Abstract

Background:

Nowadays depression is becoming one of the commonest and growing chronic disorders worldwide, especially in adolescents since they go through a sensitive stage with many physical, psychological, and cognitive changes. Prevalence of depression rises substantially throughout adolescence with female preponderance.

Objective:

This study aimed to estimate the prevalence and identify the risk factors of depression among secondary school girls in Buraydah, Al-Qassim Region, Saudi Arabia.

Subject and Methods:

A descriptive, cross-sectional study was carried out in secondary school girls section aged 15–19 years living at Buraydah city. A structured pretested questionnaire was used to collect data from 236 female students from 10 secondary schools. Data were analyzed using SPSS version 21. Written consent was taken before filling the questionnaire.

Results:

The prevalence rate of depression was 21.6%. Out of 51 depressed students, 23 (45.1%) have moderately severe depression and 19 (37.3%) were severely depressed. Only 9 (17.6%) were mildly depressed. A significant statistical relationship was detected between depression and risk factors such as the personal history of depression, exposure to sexual assault exposure to emotional or physical violence, losing a loved one, family, relative, or friend, and negative family relationship (P value < 0.05). No statistically significant relationship was found between depression and sociodemographic characteristics.

Conclusion:

The present study indicates that depression is as prevalent among secondary school girls as almost one in five was reported depression. We need more studies to measure the prevalence and determine risk factors for depression in adolescents in this region and other regions. The need is for educational programs about depression, impact, and risk factors for adolescents, parents, and teachers.

Introduction

Nowadays, depression is becoming one of the commonest and growing chronic disorders worldwide.[1] The World Health Organization has described depression as the fourth leading cause of illness and disability among adolescents aged 15–19 years.[2] Worldwide 10%–20% of children and adolescents experience behavioral problems or mental disorders.[3] Prevalence of depression rises substantially throughout adolescence with female preponderance (about 2:1 male to female ratio).[3]

Adolescent depression results in irritable (rather than low mood) behavior, loss of interest, fatigue, change in appetite and/or sleep, decreased concentration, and suicidal thought.[4] These symptoms may be ignored and considered as irritability and mood swings of adolescents or hormonal changes.[4] Depression placing adolescents at greater risk for psychological, social functioning and academic performances impairments, smoking, obesity, anxiety, substance abuse suicidal ideation, and thoughts and plan for suicide (the second-to-third leading cause of death in this age group). Studies have shown that more than half of adolescent suicide victims suffer from depression at the time of death.[5]

Since studies in this regard are very few in Qasim Region, Saudi Arabia, and never be conducted before in Buraydah city, so we conducted this study.

Subject and Methods

Out of 75 female secondary schools, 15 schools were selected randomly to participate in this study. First, we plan to enroll the girl students from the selected schools by simple random sampling methods based on the inclusion criteria. But due to the COVID-19 pandemic and the lockdown, schools were closed and shifted to online learning; as a result of this situation, we could not be able to access the participants and collect data by direct interview. Based on this unusual situation, we change the strategy of data collection from participants’ interviews into an online survey. Accordingly, the questionnaire redesigned using Google sheet.

The questionnaire was piloted on 30 female students, and it was in a similar environment for teenage female students. The female students and the schools in which they were piloted were excluded from the sample because a few questions of the questionnaire needed some modification.

After approval from the school authorities, the electronic survey was sent through social media (WhatsApp) for all levels and classes in the selected school. The questionnaire consisted of three sections: sociodemographic features, a patient health questionnaire (PHQ-9), and an assessment of risk factors. The sociodemographic profile consisted of some variables such as age, nationality, marital status, parents’ education, family income, previous personal or family history of depression, school grade, and academic scores. The second part was to assess the risk factors related to depression among the respondents, which was constructed based on the literature reviews of related research, such as the relationship with teachers and classmates, relationship with family members, physical, sexual, and verbal abuse, stressful life events, contentment with body images, and history of chronic disease for participants and their families.

The third part of the questionnaire was to assess the symptoms of depression in participants using the Arabic version patient health questionnaire (PHQ-9), as the sensitivity and specificity of the PHQ-9 among adolescents are similar to those of adult populations.

Data Management and Analysis Plan

The data were collected in an Excel sheet, coded, validated, and then imported into SPSS version 21, for Windows (SPSS, Inc., Chicago, IL, USA) for analysis. The main variables analyzed were sociodemographic characteristics, family history of depression, and the factors for depression. A Chi-squared test was used to compare the association between two proportions. A P value of ≤0.05 was considered statistically significant.

The PHQ-9 Patient Depression Questionnaire was used in this survey; it includes nine questions used to assess the depression status for the last two weeks of the respondents. For the initial diagnosis of depression, the respondent those answered yes for at least four questions out of nine, including mainly questions 1 and 2, were considered depressive.

Scoring of depression severity based on the HQ9 was on the following table:

Total score	Depression severity
1–4	Minimal depression
5–9	Mild depression
10–14	Moderate depression
15–19	Moderately severe depression
20–27	Severe depression

Ethical considerations

Institutional Ethical Committee approval was taken from Qassim Regional Ethics Committee (Letter No: 1440-1411706, Monday, March 11, 2019). A permission letter from the Education Department at the Buraydah sector was sent to the participating schools prior to the conduction of this research. Consent and voluntary participation were added at the beginning of the questionnaire, and the students were briefed on the aim of the study and were also assured that the questionnaire was anonymous and confidential.

Results

A total of 236 adolescents, consisting of females only, were studied. The characteristics of respondents and analysis of the questionnaire are described below.

Sciodemographic characteristics

In this study, age ranged from 15 to 19 years. The average age was 17.1 (SD ± 1.04) years. Most of the girl students, i.e., 203 (86.0%), were in the age group between 16 and 18 years. While a few of them were at the age of 15 years and 19 years, 11 (4.7%), and 22 (9.3%), respectively [Figure 1] most of the respondents were Saudi 228 (96.6%) [Table 1]. About half of female students 109 (46.2%) were in the 12^th grade. The rest of the students were in the 11^th grade 68 (28.8%) and 10^th grade 59 (25.0%) [Table 1]. A higher percentage of female secondary school students 136 (57.6%) had an excellent academic score. About 70 (29.7%) of them obtained very good scores, 23 (9.7%) had good scores, and a few of them, i.e., 6 (2.5%), of them had fair scores. Only one (0.4%) female student was a repeater [Table 1]. More than half, i.e., 155 (65.7%), of the female secondary schools have 5–10 siblings. About 66 (28%) of them had <5 siblings and only 15 (6.4%) had more than 10 siblings. The majority of the students were in the middle order of siblings 135 (57.2%), 47 (19.9%) were the eldest, and 54 (22.9%) were the youngest [Table 1] Most of female students were single 232(98%), only 4 (2%) of them were married [Figure2]. The majority of the participating students live with their parents, 197 (83.5%) followed by living with only the father 27 (11.4%), and a few of them live with their mother only 6 (2.5%) or others 6 (2.5%) [Table 1]. Most of the students’ parents have a primary and secondary education level, from their fathers and mothers.

Figure 1.

The Age distribution of female secondary students (n = 236)

Table 1.

Socio-demographic characteristics of the respondents (n=236)

Characteristics	Frequency (n)	Percentage (%)
Age Mean (±SD)	17.1 (±1.04) years
Nationality
Saudi	228	96.6
Non-Saudi	8	3.4
Marital status
Married	4	2
Unmarried	232	98
Education level/school grades
10th grade	59	25.0
11th grade	68	28.8
12th grade	109	46.2
Academic performance
Excellent	136	57.6
Very good	70	29.7
Good	23	9.7
Fair	6	2.5
Repeater	1	0.4
Number of siblings
<5 Siblings	66	28
5-10 Siblings	155	65.7
>10 Siblings	15	6.4
Order of respondent among sibling
Eldest	47	19.9
Middle	135	57.2
Youngest	54	22.9
Living with
Parents	197	83.5
Father only	27	11.4
Mother only	6	2.5
Others	6	2.5
Fathers’ education level
Primary and Secondary schools	129	54.6
Diploma	17	7.2
Bachelor	63	26.7
Post-graduation	27	11.4
Mothers’ education level
Illiterate	5	2.1
Primary and secondary schools	133	56.4
Diploma & Bachelor	88	37.3
Post-graduation	10	4.2
Fathers’ occupation
Governmental employee	97	41.1
Private employee	50	21.2
Unemployed	30	12.7
Others	59	25.0
Types of accommodation
Villa	182	77.1
Apartment	26	11.0
One floor flat	28	11.9
Total Monthly income
<5000 SR	43	18.2
5001-10,000 SR	72	30.5
10,001-15,000 SR	43	18.2
>15000 SR	66	28.0
I don’t know	12	5.1

Figure 2.

Marital status of female secondary school students (n = 236)

Regarding the socioeconomic status, the respondents showed different responses. The majority of them are residents in villa 182 (77.1%), while the rest are living either in apartment 26 (11%) or one floor flat 26 (11%).

Regarding monthly income and father’s’ occupation, about half of the students’ father has a government job 97 (41.1%), whereas some are working in private sector 50 (21.2%). The total monthly income of the respondents varied, the highest percentage reported was 30.5% for those who had a monthly family income between 5001–10,000 SR. Few of them said they do not know their monthly income 12 (5.1%). There is no statistically significant relationship between depression prevalence and all sociodemographic characteristics [Table 7].

Table 7.

Association of personal characteristics of the respondents with depression (n=236)

Exposure to factors known to cause mental health illness	Depressed student 51 (21.6%) n (%)	Nondepressed 185 (78.4%) n (%)	Total (n)	P
Parent or sibling with depression
No	34 (18.9)	146 (81.1)	180	0.068
Yes	17 (30.4)	39 (69.6)	56
Have you been bullied?
No	19 (16.4)	97 (83.6)	116	0.054
Yes	32 (26.7)	88 (73.3)	120
Have you ever been sexually harassed?
No	31 (18.0)	140 (81.4)	171	0.035
Yes	20 (30.8)	45 (69.2)	65
Ever experienced emotional or physical violence
No	20 (15.7)	108 (84.4)	128	0.015
Yes	31 (28.7)	77 (71.3)	108
Have you ever had depression or anxiety?
No	5 (7.7)	61 (92.4)	66	0.001
Yes	46 (27.1)	124 (72.9)	170
Have you ever thought about harming yourself or committing suicide?
No	19 (14.1)	116 (85.9)	135	0.003
Yes	32 (32.0)	68 (68.0)	100
Personal history of chronic disease or neurological disease?
No	44 (20.8)	168 (79.2)	212	0.342
Yes	7 (29.2)	17 (70.8)	24
A family history of chronic or nervous disease?
No	21 (16.9)	103 (83.1)	124	0.066
Yes	30 (26.8)	82 (73.2)	112
Personal history losing a loved one, family, relative or friend?
No	20 (15.0)	113 (85.0)	133	0.005
Yes	31 (30.1)	72 (69.9)	103
A negative family relationship
No	33 (18.1)	149 (81.9)	182	0.017
Yes	18 (33.3)	36 (66.7)	54
Not have good relationships with teachers
No	42 (20.19)	166 (79.8)	208	0.149
Yes	9 (32.14)	19 (67.85)	28
Not have good relationships with peers
No	36 (18.09)	163 (81.9)	199	0.002
Yes	15 (40.54)	22 (59.5)	37
Are you satisfied with your bodily image?
No	22 (31.88)	47 (68.1)	69	0.013
Yes	29 (17.36)	138 (82.6)	167

*P value at level of significance < 0.05

Table 3.

Severity of depression among study participants

Severity of depression	Frequency (n)	Percentage
Minimal depression	0	0
Mild depression	0	0
Moderate depression	9	17.6
Moderately severe depression	23	45.1
Severe depression	19	37.3
Total	51	100

*This depression classification is depending on (PHQ9)

Depression assessment

The prevalence rate of depression was 51 (21.6%), where 78.4% not depressed. According to PHQ 9, the depression classification was ranged into five categories from minimal to severe depression. 23 (45.1%) were moderately severe depression and 19 (37.3%) were severely depressed. Only 9 (17.6%) were mildly depressed. Most of the participants, i.e., 103 (43.6%), faced somewhat difficult to deal with any problem [Tables 2-4].

Table 2.

Prevalence of depression among female secondary school

Depression status	Frequency (n)	Percentage
Depressed	51	21.6
Not depressed	185	78.4
Total	236	100

Table 4.

Respondents’ depression assessment based on the patient health questionnaire (PHQ9)

Variables		Frequency (n)	Percentage
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people	Not difficult at all	49	20.8
	Somewhat difficult	103	43.6
	Very difficult	21	8.9
	Extremely difficult	11	4.7
	Not answered (missing data)	52	22.0
Total		236	100

192 (81%) had no family history of psychological disorders, while less than one-third of them had a positive family history of psychological disorders 44 (19%) [Figure 3]. 56.8% of them had a family history of depression, 27.3% had a family history of anxiety, and 16.3% had a family history of obsessive–compulsive disorder, while only one female student had a family history of 2.3% schizophrenia [Table 2].

Figure 3.

Family history of psychological disorders among female secondary school students (n = 236)

Exposure to risk factors

A personal history of depression or anxiety was the highest factor reported 72% compared to other factors. The participant’s dissatisfaction with body image was also found to be a high 70.8% factor. More than half of female students were exposed to bullying by 50.8%. About 45.8% of them were exposed to emotional or physical violence, and 42.4% tended to harm themself or committing suicide. On the other hand, the exposure to sexual assault 27.5%, poor relationship with parents 22.9%, peers 15.7%, and teachers 11.9%, in addition to the history of chronic diseases or neurological diseases 10.2% were the least risk factors mentioned by the participants [Table 5]. There was a statistically significant relationship between some risk factors and depression rate such as exposure to sexual assault (P = 0.035), exposure to emotional or physical violence (P = 0.015), having a personal history of depression or anxiety (P = 0.001), losing a loved one, family, relative, or friend (P = 0.005), negative family relationship (P = 0.017), not having good relationships with the peers (P = 0.002), and unsatisfaction with body image (P = 0.013) [Table 6]. Whilst Parent or sibling depression history, Personal history of chronic disease or neurological disease, no good relationships with teachers, and family history of the chronic or nervous disease are found to be not statistically significant for depression prevalence [Table 7].

Table 5.

Respondents exposure to known factors that may cause mental health illness (n=236)

Variables	Yes		No
	(n)	(%)	(n)	(%)
Have you been bullied?	120	50.8	116	49.2
Have you ever been sexually harassed?	65	27.5	171	72.5
Have you ever been exposed to emotional or physical violence?	108	45.8	128	54.2
Do you have a history of depression or anxiety?	170	72.0	66	28.0
Have you ever thought about harming yourself or committing suicide?	100	42.4	135	57.2
Did you have a history of chronic disease or neurological disease?	24	10.2	212	89.8
Did you have a family history of chronic or nervous disease?	112	47.5	124	52.5
Have you lost a loved one, family, relative or friend?	103	43.6	133	56.4
Did you have a negative family relationship?	54	22.9	182	77.1
Do you have a good relationship with teachers?	28	11.9	208	88.1
Do you have good relationships with peers?	37	15.7	199	84.3
Are you satisfied with your bodily image?	167	70.8	69	29.2

Table 6.

Prevalence of depression among secondary school girls according to their sociodemographic characteristics (n=236)

Sociodemographic Characteristics	Depressed student 51 (21.6%) n (%)	Nondepressed 185 (78.4%) n (%)	Total (n)	P
Age
15-16 years	13 (18.1)	59 (81.9)	72	0.30
17-19 years	38 (23.2)	126 (76.8)	164
Nationality
Saudi	48 (21.1)	180 (78.9)	228	0.237
Non-Saudi	3 (60.0)	5 (40.0)	8
Marital status
married	0 (0)	4 (100)	4	0.290
single	51 (22.0)	181 (78.0)	232
School grade
10th	10 (16.9)	49 (83.1)	59	0.059
11th	10 (14.7)	58 (85.3)	68
12th	31 (28.4)	78 (71.6)	109
One floor flat	7 (25)	21 (75)	28
Villa	36 (19.8)	146 (80.2)	182
Number of siblings
From 5 to 10	31 (20)	124 (80)	155	0.471
Less than 10	15 (22.7)	51 (77.3)	66
More than 10	5 (33.3)	10 (66.7)	15
Order of respondent among sibling
Eldest	7 (14.9)	40 (85.1)	47	0.378
Middle	33 (24.4)	102 (75.6)	135
Youngest	11 (20.4)	43 (79.6)	54
Academic scoring
Excellent	34 (25)	102 (75)	136
Very good	9 (12.9)	61 (87.1)	70	0.078
Good	8 (34.8)	15 (65.2)	23
fair	0 (0)	6 (100)	6
Repeater	0 (0)	1 (100)	1
Living with
father only	7 (25.9)	20 (74.1)	27
mother only	1 (16.7)	5 (83.3)	6	0.814
Parents	41 (20.8)	156 (79.2)	197
other	2 (33.3)	4 (66.7)	6
Income
<5000 SR	13 (30.2)	30 (69.8)	43
5001-10,000 SR	18 (25)	54 (75)	72	0.308
10,001-15,000 SR	7 (16.3)	36 (83.7)	43
>15,000 SR	12 (18.2)	54 (81.8)	66
I don’t know	1 (8.3)	11 (91.7)	12

*P value at level of significance <0.05

Discussion

Depression is one of the commonest psychological disorders and the leading cause of illness and disability among adolescents.[2]

The ages of adolescents in the current study sample ranged from 15 to 19. A total of 236 adolescents, consisting of females only, were studied. The mean age of the study participants was 17.1 years (SD ± 1.04). The prevalence of depression in this study is 21.6%. This is a high percentage that may affect their social and academic life as compared to other international studies; this percentage is higher than in the studies conducted in the United States, England, and Nepal, which reported a prevalence of 17.3%, 4.8%, and 11.1%, respectively.[6,7,8] However, the percentage in the current study is less than that reported by a study done in India that reporting that two-fifths (40%) of adolescents had depressive disorders.[9] The prevalence of depression in this study is in line with the results revealed by previous Saudi studies, which showed a high prevalence among adolescents in general, and among girls in particular, with an approximate range of (13%–42.9%).[10,11,12]

The prevalence of depression is higher in the current study compared to other studies could be due to several reasons. First, the current study is conducted on female adolescents only, where several local and international studies have shown that the prevalence of depression is higher among females than among males.[7,10] Second, we used a self-administered electronic questionnaire (GHQ-9) that may lead to minimal resistance in answering and better reporting by the respondents. Another important point we conducted in this study at a time of the spread of Covid-19 pandemic which may affect adolescents’ mental health: The central disease control and prevention has reported that the Covid-19 pandemic can affect adolescents’ social, emotional, and mental well-being.[13] Also, this difference may have attributed due to diverse geographical environments and economic and cultural characteristics in the methodology used. According to social demography, they all failed to show a statistically significant correlation between rates of depression in adolescents, which was supported by another study done by Dipal Patel among school-going adolescents of Rajkot, Gujarat, India.[14] However, the prevalence of depression higher among students of 12th class may be due to stress related to performance; this finding was similar to a previous study conducted in India.[9] Also, this study showed that adolescents were from low-income families (<5000 riyals/month), and those whose families lived in apartments also had higher rates of depression. Although it is not significant statistically, the relationship between depression and low income has been described in previous studies conducted among adolescents with a family income of <5000 SR; P = 0.027, as well as those whose families were living in apartments.[3,15,16,17,18,19] Our study did not find a statistically significant relationship between depression prevalence and age, family size, birth order, according to risk factors in the present study. There was a statistically significant relation between exposure to sexual assault (P = 0.035), exposure to emotional or physical violence (P = 0.015), having a personal history of depression or anxiety (P = 0.001), losing a loved one, family, relative, or friend (P = 0.005), negative family relationship (P = 0.017), not having good relationships with the peers (P = 0.002), and unsatisfied with body image (P = 0.013) and depression rate. These finding were similar to study done in Turkish.[18,24]

Early conducted studies in Saudi Arabia and Oman support that not having good relationships with peers and family, not being happy with their body images, history of psychiatric illness, and history of relative loss as statistically significant risk factors.[3,10,20,21,22] The limitation of the study was: confirmation of the diagnosis was not done, it has only investigated the prevalence and risk factors for depression only among female Saudi adolescents, which might differ from the prevalence and risk factors for depression among Saudi adolescent boys. It was performed exclusively in the City of Buridah, so it did not explor the prevalence of depression and the related risk factors among rural adolescents and prevent generalizability of the results. Questionnaires were self-administered; therefore, there is a chance for reporting bias or misunderstanding of the questions. We recommend increasing efforts for adolescent depression screening in primary health centers: increasing community awareness of mental health and depression, especially teachers and parents; and conducting a nationwide survey to determine the exact extent of depression.

To conclude, depression is a widely spread condition among adolescents in Buridah. The overall prevalence of depression in high school female students by using GHQ-9 was (21.6%).[23] Mild depression and moderately severe depression rate was more than other severity. More studies are needed to reveal the prevalence and general risk and consequences of depression, also activating a screening program for early detection of depression and educational programs for adolescents, parents, and teachers are needed.

To summarize, the prevalence of depression among adolescents in high school female students; in Buridah, by using GHQ-9, it was 21.6%. The most significant risk factors associated with depression were having a personal history of depression or anxiety, losing a loved one, family, relative, or friend, negative family relationship, not have good relationships with the peers, and unsatisfied with body image.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.