Annals of African Medicine Vol. 14, No. 1; 2015
Access this article online Quick Response Code:
Original Article
Website: www.annalsafrmed.org DOI: 10.4103/1596-3519.148737 PMID: ******
Page | 46
Depression among adolescents attending secondary schools in South East Nigeria Josephat M. Chinawa1,2, Pius C. Manyike3, Herbert A. Obu1,2, A. Ebele Aronu1,2, Odetunde Odutola1,2, Awoere Chinawa T.2,4 Department of Pediatrics, College of Medicine, University of Nigeria, University of Nigeria Teaching Hospital, 2Department of Paediatrics, Ituku Ozalla, Enugu State, 3Department of Pediatrics, Fedral Teaching Hospital, Abakiliki, Ebonyi State, 4Department of Community Medicine, University of Nigeria Teaching Hospital, Nigeria 1
Correspondence to: Dr. Josephat M. Chinawa, Department of Paediatrics, University of Nigeria Teaching Hospital, PMB 01129, Enugu 400001, Enugu State, Nigeria. E‑mail: [email protected]
Abstract Background: Depression among adolescents is an uncommon and frequently unrecognized issue in pediatrics. Children and adolescents however suffer from both depression and associated symptoms. Methods: The study was carried out among adolescents in secondary schools from two states; Enugu and Ebonyi metropolises within the age range of 9‑18 in Enugu metropolis. The instrument employed for data collection was a structured self‑administered questionnaire developed from the Goldberg Depression Questionnaire, a Screening Test for Depression. It is particularly suited for students in this age group. The families were assigned socio‑economic classes using the recommended method (modified) by Oyedeji. Objectives: The aims and objectives of this study were to determine the prevalence of several levels of depression among adolescents attending secondary schools in two states. Results: A total of 453 adolescents who are attending secondary schools from two states were recruited in this study. Depression is non‑existent before the age of 10 years according to this study. The prevalence of moderate depression was lowest (2.3%) at the age of 10 and highest at (6.2%) the age of 13. The prevalence of severe depression was lowest (1.9%) at the age of 11 and highest (7.4%) at the age of 12. Female gender is a risk factor for depression. Children whose parents are separated showed higher incidences of depression in all the spectra studied. Conclusion: Adolescents exhibit different levels of depression with a female preponderance. Keywords: Adolescents, depression, secondary schools
Résumé Contexte: Dépression chez les adolescents est un problème rare et souvent méconnu en pédiatrie. Enfants et adolescents souffrent cependant de dépression et de symptômes associés. Méthodes: L'étude a été réalisée chez les adolescents dans les écoles secondaires de deux États ; Enugu et Ebonyi métropoles dans la tranche d'âge des 9-18 à Enugu métropole. L'instrument utilisé pour la collecte de données était un questionnaire structuré mis au point de le Questionnaire de dépression de Goldberg, un Test de dépistage pour la dépression.C'estparticulièrement adapté pour les élèves de ce groupe d'âge.Les familles ont été assignés des classes socioéconomiques à l'aide de la méthode recommandée. Résultats: Un total de 453 adolescents qui fréquentent les écoles secondaires de deux États ont été recrutés dans cette étude. La dépression n'existe pas avant l'âge de 10 ans, selon cette étude. La prévalence de la dépression modérée était le plus bas (2,3 %) à l'âge de 10 et plus haut (6,2 %) à l'âge de 13. La prévalence de la dépression sévère a été plus faible (1,9 %) à l'âge de 11 et le plus élevé (7,4 %) à de 12 ans. Sexe féminin est un facteur de risque pour la
Vol. 14, January-March, 2015
Annals of African Medicine
Chinawa, et al.: Depression among adolescents attending secondary schools in South East Nigeria dépression. Enfants dont les parents sont séparés, a montré une incidence plus élevée de la dépression dans tous les spectres étudiés. Conclusion : Adolescents présentent différents niveaux de dépression avec une prépondérance féminine. Mots-clés : Adolescents, dépression, écoles secondaires
Introduction Depression is defined as a state of low mood and aversion to activity.[1] It is noted that several controversies characterize the literature on depression in adolescents. For instance, some studies noted that children and young adolescents did not have the psychological structure (e.g., superego functions) to truly experience depression.[2,3] Indeed, the classic characterization of adolescence as a time of “storm and stress” led many researchers to view depression during adolescence as a normal developmental stage.[4] In fact, most adolescents progress through life without undue emotional turbulence.[2] In contrast, it is known and documented that children and adolescents do indeed suffer from both depressive symptoms and depressive disorders.[3] In fact, adolescence is a critical period for the development of depressive disorders.[3] As unrecognized as depression is among the adult population, it is even more so among children and adolescents. [5] Studies have estimated that depression affects up to 8.3% of older adolescents in the United States.[5] In addition, it is noted that on any single day, about 2% of school‑aged children and about 8% of adolescents meet the criteria for major depression.[6] In the long run, the numbers are even higher, for example, one in five adolescents have experienced depression at some point.[7] In primary care settings, the rates of depression are as high as 28% for adolescents.[7] Depressive symptoms among adolescents are often attributed to the normal stress seen at this stage of life.[8] This is often misdiagnosed as primarily conduct or substance abuse disorders. Neglecting depression among adolescents can have a tragic and deleterious effect.[8] Depression is associated with an increased risk of suicide and it is well‑known that suicide rates among adolescents have nearly tripled in the last 50 years.[8] Regrettably, adolescents who experience depression at an early age often struggle with depression throughout their lives.[9] Furthermore early onset of depression predicts more severe depression during adulthood.[10] Even subclinical depression during adolescence increases the risk of major depression disorders 2‑ to 3‑fold as an adult.[10] Gender is known to influence depression in adolescents. For instance, in childhood, the number Annals of African Medicine
of boys and girls affected are almost equal. [11] In adolescence, twice as many girls as boys are diagnosed.[11] It is surprising to note that more than half of depressed adolescents have a recurrence within 7 years. Several factors increase the risk of depression, including a family history of mood disorders and stressful life events.[11]
Methods Study area The study was carried out among adolescents in secondary schools from two states; Enugu and Ebonyi metropolises within the age range of 9‑18 in Enugu metropolis. These states have almost similar socio‑demographic characteristics when compared to other states in Nigeria. Multistage sampling was carried out where we selected the two eastern states, Enugu and Ebonyi.
Study population The questionnaire was self‑administered to the students, but outside class and lesson hours. The school proprietress was asked for permission to recruit students. Consent was obtained from the head of the institutions after they had been told that their participation was completely voluntary in nature and that they could discontinue their involvement at any time. Enugu has a population of 3.5 million while Ebonyi state has a population of 126,837 people according to the national population census. [12] Anonymity and confidentiality of responses were also conveyed, we also assure them that teachers and care‑givers would not be given access to the data. The subjects were children who attend secondary school in Enugu and Ebonyi metropolises. The secondary school provides a complete school health program. They have qualified teachers and health instructors.
Study procedure The instrument employed for data collection was a structured self‑administered questionnaire developed from the modified Goldberg Depression Questionnaire, a Screening Test for Depression.[13] It is particularly suited for students in this age group. The questionnaire contains 18 items with each item bearing 5 sub questions. These questions are graded. A total score of 0‑9 shows: No depression likely, moderate depression: 36‑5 and severe depression: 54 and up. The higher number, the more severe the depression. Vol. 14, January-March, 2015
Page | 47
Chinawa, et al.: Depression among adolescents attending secondary schools in South East Nigeria
Page | 48
The families were assigned socio‑economic classes (SEC) using the recommended method (modified) by Oyedeji.[14] The parents’ occupation and highest education attained were scored from 1 (highest) to 5 (lowest). The mean score for both parents gives social class falling within the 1‑5 range. Those with the mean score of 2 were reclassified into lower social class. For the occupation score, those in upper social class included parents, such as senior public officers, large‑scale traders, large‑scale farmers and professionals. Lower class included artisans, primary school teachers, peasant farmers, laborers and the unemployed. For the education score, those with PhD, master degree, bachelor degree and higher national diploma were categorized as upper class. Those with ordinary national diploma, national certificate of education, technical education, Grade II teachers’ certificate, junior and senior secondary school certificate, primary school certificate and those with no formal education were classified as lower social class.[14] The aims and objectives of this study were to determine the prevalence of several levels of depression among adolescents attending secondary schools in two states; to describe the correlation between gender, SEC and depression.
Data analysis Data was analyzed with Statistical Package for Social Sciences (SPSS)(Chicago Il, USA)) software, version 17. Data presentation was in form of tables and charts. Frequencies, proportions and percentages were calculated for categorical variable. Results of continuous variables were expressed as medians. Pearson’s Chi‑square was used to test for relationship between categorical variables while Student’s t‑test was used to test significant relationship between continuous variables. Test of significance was set at P 54 (severe depression) test score (%) (%) (%) Age 8 1 (100) 0 0 9 2 (100) 0 0 10 36 (59.0) 2 (2.3) 0 11 62 (58.5) 3 (2.8) 2 (1.9) 12 16 (59.3) 1 (3.7) 2 (7.4) 13 6 (37.5) 1 (6.2) 1 (6.2) 14 10 (25.0) 1 (2.5) 0 15 39 (46.4) 4 (4.8) 4 (4.8) 16 19 (25.3) 4 (5.3) 1 (1.4) 17 13 (36.1) 2 (5.6) 1 (2.8) 18 2 (40) 0 0 Sex Female 114 (44.7) 13 (5.1) 8 (3.1) Male 92 (46.5) 5 (2.5) 3 (1.5) SEC 1 (high SEC) 64 (46.0) 8 (5.8) 3 (2.2) 2‑3 (middle SEC) 141 (45.2) 10 (3.2) 8 (2.6) 4‑5 (low SEC) 1 (50) 0 0 Parents together No 6 (28.6) 1 (4.8) 1 (4.8) Yes 200 (46.3) 17 (3.9) 10 (2.7)
χ2
P value
69.928 0.033
Page | 49
3.503
0.623
7.997
0.629
7.562
0.182
SEC=Socio‑economic class
of this menace. The prevalence of depression among adolescent from this study is noted to increase slightly as the adolescents grow older but tends to be at its lowest ebb at extremes of ages. The prevalence of moderate depression was lowest (2.3%) at the age of 10 and highest at (6.2%) the age of 13 while that of severe depression was lowest (1.9%) at the age of 11 and highest (7.4%) at the age of 12. This is similar to the findings of Mathet et al.,[15] in their study noted that more than 10% children aged less than 13 years had a depressive disorder and that the prevalence in the adolescent sub‑group was 5%. All depressive disorders were moderate. Furthermore, Bansal et al.,[16] also noted that three to nine per cent of teenagers meet the criteria for depression at any one time and at the end of adolescence, as many as 20% of teenagers report a lifetime prevalence of depression. When we looked at total prevalence of depression among adolescents in our study, it far outweighs that of Bansal. One of the arguments against the construct of adolescent depression is the “general emotional roller coaster” state of adolescent change. This is probably the reason why we did not consider mild depression in adolescent. We noted with interest, from this study, that depression of all forms is commonest among females. This is in tandem with the work of Hankin and Abramson[17] and Piccinelli et al.,[18] who noted that more than twice as many girls as boys are depressed, a proportion that persists into Annals of African Medicine
adulthood.[15] Reasons ranging from biological, genetic, psychosocial, hormonal to family factors have been pointed out as possible cause for this gender difference. [18] Bennett et al.,[19] in their study noted no gender difference of depression among adolescents. He noted that the experience of depression is highly similar for adolescent girls and boys. He concluded that some gender differences previously found among depressed adults appear to be present by adolescence, possibly suggesting somewhat distinct etiologies for depression among males and females. Adolescents whose parents are separated showed higher incidences of depression in all the spectra studied. Parental separation experiences place the adolescent in an insecure situation. This may affect both their feelings of self‑worth and their ability to establish stable and secure attachments with their peers.[20] In addition, some authors[21,22] have noted the link between parental separation/divorce and depressive symptoms among adolescents. Apart from parental separation, other childhood stressors of depression include family history of depression and poor school performance. [23] Unfortunately, we did not find out if there is any history of parental depression neither did we look into the academic performance of the adolescents. There is a generally higher incidence of depression in the middle SEC, followed by high SEC. This finding varies from other studies where parents Vol. 14, January-March, 2015
Chinawa, et al.: Depression among adolescents attending secondary schools in South East Nigeria
from low SEC are likely to have depressed adolescents. For instance, Gilman et al.[24] found that low parental SEC increased risk for depression among adolescent. Moreover, Ritsher et al., [25] noted that low parental socio‑economic class does have an independent impact on offspring depression but the strength of this impact varies across groups. Page | 50
We noted from this study that adolescents who are depressed (especially severe depression) sleep at fewer hours when compared with adolescents without depression or with mild depression. This finding is in tandem with Urrila et al.,[26] who noted a close link between sleep disturbances and depression in adolescent outpatients with major depressive disorders. The possible reason for this strong correlation between depression and sleep problem could be due to some neuro‑hormonal imbalance. This study revealed a positive correlation between depression and weight gain among adolescents. Adolescents (especially those who are severely depressed) admitted that they are gaining weight. It is bewildering, if weight gain leads to depression or vice versa. However evidence abound to show that depression leads to weight gain, for instance depression releases some stress hormone; cortisol which stimulates and promotes fat storage, especially in the abdominal area. The hormone also leads to depressed affect, which then leads to excess weight gain.[27] This finding is also supported by Grossniklaus et al.[28] who noted that subjects who had severe depressive symptoms experienced a faster rate of increase in body mass index and waist circumference over time than those who reported fewer symptoms of depression.
Conclusion
3. 4.
5.
6.
7.
8.
9.
10.
11.
12. 13.
14.
15.
16.
17.
Adolescents exhibit different levels of depression with a female preponderance.
18.
Acknowledgments
19.
We acknowledge the almighty God whose assistance and ideas throughout the course of this work were priceless. Also being appreciated are staff and principals of the school.
20.
References 1.
2.
Birmaher B, Ryan ND, Williamson DE, Brent DA, Kaufman J, Dahl RE, et al. Childhood and adolescent depression: A review of the past 10 years. Part I. J Am Acad Child Adolesc Psychiatry 1996;35:1427‑39. Saluja G, Iachan R, Scheidt PC, Overpeck MD, Sun W, Giedd JN. Prevalence of and risk factors for depressive
Vol. 14, January-March, 2015
21.
22. 23.
symptoms among young adolescents. Arch Pediatr Adolesc Med 2004;158:760‑5. Luby JL. Early childhood depression. Am J Psychiatry 2009;166:974‑9. Perou R, Bitsko RH, Blumberg SJ, Pastor P, Ghandour RM, Gfroerer JC, et al. Mental health surveillance among children – United States, 2005‑2011. MMWR Surveill Summ 2013;62 Suppl 2:1‑35. Lewinsohn PM, Rohde P, Klein DN, Seeley JR. Natural course of adolescent major depressive disorder: I. Continuity into young adulthood. J Am Acad Child Adolesc Psychiatry 1999;38:56‑63. Kessler RC, Avenevoli S, Ries Merikangas K. Mood disorders in children and adolescents: An epidemiologic perspective. Biol Psychiatry 2001;49:1002‑14. Amy HC, Rachel AZ, Peter SJ, Kareem G, Danielle L, Ruth EK, et al. Guidelines for Adolescent Depression in Primary Care (GLAD‑PC): II. Treatment and Ongoing Management. Pediatrics 2007;120:1313‑26. Centers for Disease Control, Suicide in the United States. Available from: http://www.cdc.gov/ncipc/factsheets/ suifacts.htm. [Last accessed on 2003 Dec 16]. Brooks TL, Harris SK, Thrall JS, Woods ER. Association of adolescent risk behaviors with mental health symptoms in high school students. J Adolesc Health 2002;31:240‑6. Pine DS, Cohen P, Gurley D, Brook J, Ma Y. The risk for early‑adulthood anxiety and depressive disorders in adolescents with anxiety and depressive disorders. Arch Gen Psychiatry 1998;55:56‑64. Eapen V, Črnčec R. Strategies and challenges in the management of adolescent depression. Curr Opin Psychiatry 2012;25:7‑13. National Population Commission 2006 Provisional Census Figures. Census News 2006;31:14. Goldberg Depression Questionnaire, a Screening Test for Depression. Available from: http://www.psychcentral. com/depquiz.htm. [Last accessed on 2013 Dec 27]. Oyedeji GA. Socio‑economic and cultural background of hospitalized children in llesha. Niger J Paediatr 1985;12:111‑7. Mathet F, Martin‑Guehl C, Maurice‑Tison S, Bouvard MP. Prevalence of depressive disorders in children and adolescents attending primary care. A survey with the Aquitaine Sentinelle Network. Encephale 2003;29:391‑400. Bansal V, Goyal S, Srivastava K. Study of prevalence of depression in adolescent students of a public school. Ind Psychiatry J 2009;18:43‑6. Hankin BL, Abramson LY. Development of gender differences in depression: Description and possible explanations. Ann Med 1999;31:372‑9. Piccinelli M, Wilkinson G. Gender differences in d e p res s i o n . C r i t i ca l re v i e w. B r J P s y ch i a tr y 2000;177:486‑92. Bennett DS, Ambrosini PJ, Kudes D, Metz C, Rabinovich H. Gender differences in adolescent depression: Do symptoms differ for boys and girls? J Affect Disord 2005;89:35‑44. Séguin M, Manion I, Cloutier P, McEvoy L, Cappelli M. Adolescent depression, family psychopathology and parent/child relations: A case control study. Can Child Adolesc Psychiatr Rev 2003;12:2‑9. Takakura M, Sakihara S. Gender differences in the association between psychosocial factors and depressive symptoms in Japanese junior high school students. J Epidemiol 2000;10:383‑91. Said B, Hasan K. Prevalence of depressive symptoms in Turkish adolescents. Eur J Gen Med 2009;6:204‑12. Son SE, Kirchner JT. Depression in children and adolescents. Am Fam Physician 2000;62:2297‑308, 2311‑2.
Annals of African Medicine
Chinawa, et al.: Depression among adolescents attending secondary schools in South East Nigeria 24. Gilman SE, Kawachi I, Fitzmaurice GM, Buka SL. Socioeconomic status in childhood and the lifetime risk of major depression. Int J Epidemiol 2002;31:359‑67. 25. Ritsher JE, Warner V, Johnson JG, Dohrenwend BP. Inter‑generational longitudinal study of social class and depression: A test of social causation and social selection models. Br J Psychiatry Suppl 2001;40:s84‑90. 26. Urrila AS, Karlsson L, Kiviruusu O, Pelkonen M, Strandholm T, Marttunen M. Sleep complaints among adolescent outpatients with major depressive disorder. Sleep Med 2012;13:816‑23. 27. Exploring the links between depression and weight gain. Available from: http://www.well.blogs.nytimes.
Annals of African Medicine
com/2010/06/16/exploring‑the-links‑between‑depres sion‑and‑weight‑. [Last accessed on 2013 Dec 06]. 28. Grossniklaus DA, Gary RA, Higgins MK, Dunbar SB. Biobehavioral and psychological differences between overweight adults with and without waist circumference risk. Res Nurs Health 2010;33:539‑51.
Cite this article as: Chinawa JM, Manyike PC, Obu HA, Aronu AE, Odutola O, Chinawa AT. Depression among adolescents attending secondary schools in South East Nigeria. Ann Afr Med 2015;14:46-51. Source of Support: Nil, Conflict of Interest: None declared.
Vol. 14, January-March, 2015
Page | 51
Copyright of Annals of African Medicine is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Access this article online Quick Response Code:
Original Article
Website: www.annalsafrmed.org DOI: 10.4103/1596-3519.148737 PMID: ******
Page | 46
Depression among adolescents attending secondary schools in South East Nigeria Josephat M. Chinawa1,2, Pius C. Manyike3, Herbert A. Obu1,2, A. Ebele Aronu1,2, Odetunde Odutola1,2, Awoere Chinawa T.2,4 Department of Pediatrics, College of Medicine, University of Nigeria, University of Nigeria Teaching Hospital, 2Department of Paediatrics, Ituku Ozalla, Enugu State, 3Department of Pediatrics, Fedral Teaching Hospital, Abakiliki, Ebonyi State, 4Department of Community Medicine, University of Nigeria Teaching Hospital, Nigeria 1
Correspondence to: Dr. Josephat M. Chinawa, Department of Paediatrics, University of Nigeria Teaching Hospital, PMB 01129, Enugu 400001, Enugu State, Nigeria. E‑mail: [email protected]
Abstract Background: Depression among adolescents is an uncommon and frequently unrecognized issue in pediatrics. Children and adolescents however suffer from both depression and associated symptoms. Methods: The study was carried out among adolescents in secondary schools from two states; Enugu and Ebonyi metropolises within the age range of 9‑18 in Enugu metropolis. The instrument employed for data collection was a structured self‑administered questionnaire developed from the Goldberg Depression Questionnaire, a Screening Test for Depression. It is particularly suited for students in this age group. The families were assigned socio‑economic classes using the recommended method (modified) by Oyedeji. Objectives: The aims and objectives of this study were to determine the prevalence of several levels of depression among adolescents attending secondary schools in two states. Results: A total of 453 adolescents who are attending secondary schools from two states were recruited in this study. Depression is non‑existent before the age of 10 years according to this study. The prevalence of moderate depression was lowest (2.3%) at the age of 10 and highest at (6.2%) the age of 13. The prevalence of severe depression was lowest (1.9%) at the age of 11 and highest (7.4%) at the age of 12. Female gender is a risk factor for depression. Children whose parents are separated showed higher incidences of depression in all the spectra studied. Conclusion: Adolescents exhibit different levels of depression with a female preponderance. Keywords: Adolescents, depression, secondary schools
Résumé Contexte: Dépression chez les adolescents est un problème rare et souvent méconnu en pédiatrie. Enfants et adolescents souffrent cependant de dépression et de symptômes associés. Méthodes: L'étude a été réalisée chez les adolescents dans les écoles secondaires de deux États ; Enugu et Ebonyi métropoles dans la tranche d'âge des 9-18 à Enugu métropole. L'instrument utilisé pour la collecte de données était un questionnaire structuré mis au point de le Questionnaire de dépression de Goldberg, un Test de dépistage pour la dépression.C'estparticulièrement adapté pour les élèves de ce groupe d'âge.Les familles ont été assignés des classes socioéconomiques à l'aide de la méthode recommandée. Résultats: Un total de 453 adolescents qui fréquentent les écoles secondaires de deux États ont été recrutés dans cette étude. La dépression n'existe pas avant l'âge de 10 ans, selon cette étude. La prévalence de la dépression modérée était le plus bas (2,3 %) à l'âge de 10 et plus haut (6,2 %) à l'âge de 13. La prévalence de la dépression sévère a été plus faible (1,9 %) à l'âge de 11 et le plus élevé (7,4 %) à de 12 ans. Sexe féminin est un facteur de risque pour la
Vol. 14, January-March, 2015
Annals of African Medicine
Chinawa, et al.: Depression among adolescents attending secondary schools in South East Nigeria dépression. Enfants dont les parents sont séparés, a montré une incidence plus élevée de la dépression dans tous les spectres étudiés. Conclusion : Adolescents présentent différents niveaux de dépression avec une prépondérance féminine. Mots-clés : Adolescents, dépression, écoles secondaires
Introduction Depression is defined as a state of low mood and aversion to activity.[1] It is noted that several controversies characterize the literature on depression in adolescents. For instance, some studies noted that children and young adolescents did not have the psychological structure (e.g., superego functions) to truly experience depression.[2,3] Indeed, the classic characterization of adolescence as a time of “storm and stress” led many researchers to view depression during adolescence as a normal developmental stage.[4] In fact, most adolescents progress through life without undue emotional turbulence.[2] In contrast, it is known and documented that children and adolescents do indeed suffer from both depressive symptoms and depressive disorders.[3] In fact, adolescence is a critical period for the development of depressive disorders.[3] As unrecognized as depression is among the adult population, it is even more so among children and adolescents. [5] Studies have estimated that depression affects up to 8.3% of older adolescents in the United States.[5] In addition, it is noted that on any single day, about 2% of school‑aged children and about 8% of adolescents meet the criteria for major depression.[6] In the long run, the numbers are even higher, for example, one in five adolescents have experienced depression at some point.[7] In primary care settings, the rates of depression are as high as 28% for adolescents.[7] Depressive symptoms among adolescents are often attributed to the normal stress seen at this stage of life.[8] This is often misdiagnosed as primarily conduct or substance abuse disorders. Neglecting depression among adolescents can have a tragic and deleterious effect.[8] Depression is associated with an increased risk of suicide and it is well‑known that suicide rates among adolescents have nearly tripled in the last 50 years.[8] Regrettably, adolescents who experience depression at an early age often struggle with depression throughout their lives.[9] Furthermore early onset of depression predicts more severe depression during adulthood.[10] Even subclinical depression during adolescence increases the risk of major depression disorders 2‑ to 3‑fold as an adult.[10] Gender is known to influence depression in adolescents. For instance, in childhood, the number Annals of African Medicine
of boys and girls affected are almost equal. [11] In adolescence, twice as many girls as boys are diagnosed.[11] It is surprising to note that more than half of depressed adolescents have a recurrence within 7 years. Several factors increase the risk of depression, including a family history of mood disorders and stressful life events.[11]
Methods Study area The study was carried out among adolescents in secondary schools from two states; Enugu and Ebonyi metropolises within the age range of 9‑18 in Enugu metropolis. These states have almost similar socio‑demographic characteristics when compared to other states in Nigeria. Multistage sampling was carried out where we selected the two eastern states, Enugu and Ebonyi.
Study population The questionnaire was self‑administered to the students, but outside class and lesson hours. The school proprietress was asked for permission to recruit students. Consent was obtained from the head of the institutions after they had been told that their participation was completely voluntary in nature and that they could discontinue their involvement at any time. Enugu has a population of 3.5 million while Ebonyi state has a population of 126,837 people according to the national population census. [12] Anonymity and confidentiality of responses were also conveyed, we also assure them that teachers and care‑givers would not be given access to the data. The subjects were children who attend secondary school in Enugu and Ebonyi metropolises. The secondary school provides a complete school health program. They have qualified teachers and health instructors.
Study procedure The instrument employed for data collection was a structured self‑administered questionnaire developed from the modified Goldberg Depression Questionnaire, a Screening Test for Depression.[13] It is particularly suited for students in this age group. The questionnaire contains 18 items with each item bearing 5 sub questions. These questions are graded. A total score of 0‑9 shows: No depression likely, moderate depression: 36‑5 and severe depression: 54 and up. The higher number, the more severe the depression. Vol. 14, January-March, 2015
Page | 47
Chinawa, et al.: Depression among adolescents attending secondary schools in South East Nigeria
Page | 48
The families were assigned socio‑economic classes (SEC) using the recommended method (modified) by Oyedeji.[14] The parents’ occupation and highest education attained were scored from 1 (highest) to 5 (lowest). The mean score for both parents gives social class falling within the 1‑5 range. Those with the mean score of 2 were reclassified into lower social class. For the occupation score, those in upper social class included parents, such as senior public officers, large‑scale traders, large‑scale farmers and professionals. Lower class included artisans, primary school teachers, peasant farmers, laborers and the unemployed. For the education score, those with PhD, master degree, bachelor degree and higher national diploma were categorized as upper class. Those with ordinary national diploma, national certificate of education, technical education, Grade II teachers’ certificate, junior and senior secondary school certificate, primary school certificate and those with no formal education were classified as lower social class.[14] The aims and objectives of this study were to determine the prevalence of several levels of depression among adolescents attending secondary schools in two states; to describe the correlation between gender, SEC and depression.
Data analysis Data was analyzed with Statistical Package for Social Sciences (SPSS)(Chicago Il, USA)) software, version 17. Data presentation was in form of tables and charts. Frequencies, proportions and percentages were calculated for categorical variable. Results of continuous variables were expressed as medians. Pearson’s Chi‑square was used to test for relationship between categorical variables while Student’s t‑test was used to test significant relationship between continuous variables. Test of significance was set at P 54 (severe depression) test score (%) (%) (%) Age 8 1 (100) 0 0 9 2 (100) 0 0 10 36 (59.0) 2 (2.3) 0 11 62 (58.5) 3 (2.8) 2 (1.9) 12 16 (59.3) 1 (3.7) 2 (7.4) 13 6 (37.5) 1 (6.2) 1 (6.2) 14 10 (25.0) 1 (2.5) 0 15 39 (46.4) 4 (4.8) 4 (4.8) 16 19 (25.3) 4 (5.3) 1 (1.4) 17 13 (36.1) 2 (5.6) 1 (2.8) 18 2 (40) 0 0 Sex Female 114 (44.7) 13 (5.1) 8 (3.1) Male 92 (46.5) 5 (2.5) 3 (1.5) SEC 1 (high SEC) 64 (46.0) 8 (5.8) 3 (2.2) 2‑3 (middle SEC) 141 (45.2) 10 (3.2) 8 (2.6) 4‑5 (low SEC) 1 (50) 0 0 Parents together No 6 (28.6) 1 (4.8) 1 (4.8) Yes 200 (46.3) 17 (3.9) 10 (2.7)
χ2
P value
69.928 0.033
Page | 49
3.503
0.623
7.997
0.629
7.562
0.182
SEC=Socio‑economic class
of this menace. The prevalence of depression among adolescent from this study is noted to increase slightly as the adolescents grow older but tends to be at its lowest ebb at extremes of ages. The prevalence of moderate depression was lowest (2.3%) at the age of 10 and highest at (6.2%) the age of 13 while that of severe depression was lowest (1.9%) at the age of 11 and highest (7.4%) at the age of 12. This is similar to the findings of Mathet et al.,[15] in their study noted that more than 10% children aged less than 13 years had a depressive disorder and that the prevalence in the adolescent sub‑group was 5%. All depressive disorders were moderate. Furthermore, Bansal et al.,[16] also noted that three to nine per cent of teenagers meet the criteria for depression at any one time and at the end of adolescence, as many as 20% of teenagers report a lifetime prevalence of depression. When we looked at total prevalence of depression among adolescents in our study, it far outweighs that of Bansal. One of the arguments against the construct of adolescent depression is the “general emotional roller coaster” state of adolescent change. This is probably the reason why we did not consider mild depression in adolescent. We noted with interest, from this study, that depression of all forms is commonest among females. This is in tandem with the work of Hankin and Abramson[17] and Piccinelli et al.,[18] who noted that more than twice as many girls as boys are depressed, a proportion that persists into Annals of African Medicine
adulthood.[15] Reasons ranging from biological, genetic, psychosocial, hormonal to family factors have been pointed out as possible cause for this gender difference. [18] Bennett et al.,[19] in their study noted no gender difference of depression among adolescents. He noted that the experience of depression is highly similar for adolescent girls and boys. He concluded that some gender differences previously found among depressed adults appear to be present by adolescence, possibly suggesting somewhat distinct etiologies for depression among males and females. Adolescents whose parents are separated showed higher incidences of depression in all the spectra studied. Parental separation experiences place the adolescent in an insecure situation. This may affect both their feelings of self‑worth and their ability to establish stable and secure attachments with their peers.[20] In addition, some authors[21,22] have noted the link between parental separation/divorce and depressive symptoms among adolescents. Apart from parental separation, other childhood stressors of depression include family history of depression and poor school performance. [23] Unfortunately, we did not find out if there is any history of parental depression neither did we look into the academic performance of the adolescents. There is a generally higher incidence of depression in the middle SEC, followed by high SEC. This finding varies from other studies where parents Vol. 14, January-March, 2015
Chinawa, et al.: Depression among adolescents attending secondary schools in South East Nigeria
from low SEC are likely to have depressed adolescents. For instance, Gilman et al.[24] found that low parental SEC increased risk for depression among adolescent. Moreover, Ritsher et al., [25] noted that low parental socio‑economic class does have an independent impact on offspring depression but the strength of this impact varies across groups. Page | 50
We noted from this study that adolescents who are depressed (especially severe depression) sleep at fewer hours when compared with adolescents without depression or with mild depression. This finding is in tandem with Urrila et al.,[26] who noted a close link between sleep disturbances and depression in adolescent outpatients with major depressive disorders. The possible reason for this strong correlation between depression and sleep problem could be due to some neuro‑hormonal imbalance. This study revealed a positive correlation between depression and weight gain among adolescents. Adolescents (especially those who are severely depressed) admitted that they are gaining weight. It is bewildering, if weight gain leads to depression or vice versa. However evidence abound to show that depression leads to weight gain, for instance depression releases some stress hormone; cortisol which stimulates and promotes fat storage, especially in the abdominal area. The hormone also leads to depressed affect, which then leads to excess weight gain.[27] This finding is also supported by Grossniklaus et al.[28] who noted that subjects who had severe depressive symptoms experienced a faster rate of increase in body mass index and waist circumference over time than those who reported fewer symptoms of depression.
Conclusion
3. 4.
5.
6.
7.
8.
9.
10.
11.
12. 13.
14.
15.
16.
17.
Adolescents exhibit different levels of depression with a female preponderance.
18.
Acknowledgments
19.
We acknowledge the almighty God whose assistance and ideas throughout the course of this work were priceless. Also being appreciated are staff and principals of the school.
20.
References 1.
2.
Birmaher B, Ryan ND, Williamson DE, Brent DA, Kaufman J, Dahl RE, et al. Childhood and adolescent depression: A review of the past 10 years. Part I. J Am Acad Child Adolesc Psychiatry 1996;35:1427‑39. Saluja G, Iachan R, Scheidt PC, Overpeck MD, Sun W, Giedd JN. Prevalence of and risk factors for depressive
Vol. 14, January-March, 2015
21.
22. 23.
symptoms among young adolescents. Arch Pediatr Adolesc Med 2004;158:760‑5. Luby JL. Early childhood depression. Am J Psychiatry 2009;166:974‑9. Perou R, Bitsko RH, Blumberg SJ, Pastor P, Ghandour RM, Gfroerer JC, et al. Mental health surveillance among children – United States, 2005‑2011. MMWR Surveill Summ 2013;62 Suppl 2:1‑35. Lewinsohn PM, Rohde P, Klein DN, Seeley JR. Natural course of adolescent major depressive disorder: I. Continuity into young adulthood. J Am Acad Child Adolesc Psychiatry 1999;38:56‑63. Kessler RC, Avenevoli S, Ries Merikangas K. Mood disorders in children and adolescents: An epidemiologic perspective. Biol Psychiatry 2001;49:1002‑14. Amy HC, Rachel AZ, Peter SJ, Kareem G, Danielle L, Ruth EK, et al. Guidelines for Adolescent Depression in Primary Care (GLAD‑PC): II. Treatment and Ongoing Management. Pediatrics 2007;120:1313‑26. Centers for Disease Control, Suicide in the United States. Available from: http://www.cdc.gov/ncipc/factsheets/ suifacts.htm. [Last accessed on 2003 Dec 16]. Brooks TL, Harris SK, Thrall JS, Woods ER. Association of adolescent risk behaviors with mental health symptoms in high school students. J Adolesc Health 2002;31:240‑6. Pine DS, Cohen P, Gurley D, Brook J, Ma Y. The risk for early‑adulthood anxiety and depressive disorders in adolescents with anxiety and depressive disorders. Arch Gen Psychiatry 1998;55:56‑64. Eapen V, Črnčec R. Strategies and challenges in the management of adolescent depression. Curr Opin Psychiatry 2012;25:7‑13. National Population Commission 2006 Provisional Census Figures. Census News 2006;31:14. Goldberg Depression Questionnaire, a Screening Test for Depression. Available from: http://www.psychcentral. com/depquiz.htm. [Last accessed on 2013 Dec 27]. Oyedeji GA. Socio‑economic and cultural background of hospitalized children in llesha. Niger J Paediatr 1985;12:111‑7. Mathet F, Martin‑Guehl C, Maurice‑Tison S, Bouvard MP. Prevalence of depressive disorders in children and adolescents attending primary care. A survey with the Aquitaine Sentinelle Network. Encephale 2003;29:391‑400. Bansal V, Goyal S, Srivastava K. Study of prevalence of depression in adolescent students of a public school. Ind Psychiatry J 2009;18:43‑6. Hankin BL, Abramson LY. Development of gender differences in depression: Description and possible explanations. Ann Med 1999;31:372‑9. Piccinelli M, Wilkinson G. Gender differences in d e p res s i o n . C r i t i ca l re v i e w. B r J P s y ch i a tr y 2000;177:486‑92. Bennett DS, Ambrosini PJ, Kudes D, Metz C, Rabinovich H. Gender differences in adolescent depression: Do symptoms differ for boys and girls? J Affect Disord 2005;89:35‑44. Séguin M, Manion I, Cloutier P, McEvoy L, Cappelli M. Adolescent depression, family psychopathology and parent/child relations: A case control study. Can Child Adolesc Psychiatr Rev 2003;12:2‑9. Takakura M, Sakihara S. Gender differences in the association between psychosocial factors and depressive symptoms in Japanese junior high school students. J Epidemiol 2000;10:383‑91. Said B, Hasan K. Prevalence of depressive symptoms in Turkish adolescents. Eur J Gen Med 2009;6:204‑12. Son SE, Kirchner JT. Depression in children and adolescents. Am Fam Physician 2000;62:2297‑308, 2311‑2.
Annals of African Medicine
Chinawa, et al.: Depression among adolescents attending secondary schools in South East Nigeria 24. Gilman SE, Kawachi I, Fitzmaurice GM, Buka SL. Socioeconomic status in childhood and the lifetime risk of major depression. Int J Epidemiol 2002;31:359‑67. 25. Ritsher JE, Warner V, Johnson JG, Dohrenwend BP. Inter‑generational longitudinal study of social class and depression: A test of social causation and social selection models. Br J Psychiatry Suppl 2001;40:s84‑90. 26. Urrila AS, Karlsson L, Kiviruusu O, Pelkonen M, Strandholm T, Marttunen M. Sleep complaints among adolescent outpatients with major depressive disorder. Sleep Med 2012;13:816‑23. 27. Exploring the links between depression and weight gain. Available from: http://www.well.blogs.nytimes.
Annals of African Medicine
com/2010/06/16/exploring‑the-links‑between‑depres sion‑and‑weight‑. [Last accessed on 2013 Dec 06]. 28. Grossniklaus DA, Gary RA, Higgins MK, Dunbar SB. Biobehavioral and psychological differences between overweight adults with and without waist circumference risk. Res Nurs Health 2010;33:539‑51.
Cite this article as: Chinawa JM, Manyike PC, Obu HA, Aronu AE, Odutola O, Chinawa AT. Depression among adolescents attending secondary schools in South East Nigeria. Ann Afr Med 2015;14:46-51. Source of Support: Nil, Conflict of Interest: None declared.
Vol. 14, January-March, 2015
Page | 51
Copyright of Annals of African Medicine is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
