Introduction

Depression is a major contributor to the global burden of disease and has impacted a significant number of people across the world [1]. It has become a prevalent form of mental illness, distinguished by symptoms such as sadness, lack of enjoyment, emotions of shame or low self-esteem, disturbed sleep and appetite, feelings of tiredness, and difficulty concentrating [1, 2]. In 2019, approximately 3.8% of the global population, comprising 280 million people, suffered from depression, making it one of the major contributors to the global disease burden [3–5]. The global data also highlights almost 14% of adolescents aged 10–19 years worldwide were affected by any form of mental health conditions in 2021 [6]. Adolescent depression is emerging at an alarming rate throughout the world. A systematic review and meta-analysis revealed that the worldwide pooled prevalence of mental disorders among children and adolescents was 13.4% [7]. In South Asian regions the prevalence of depression among school-going children has been reported at 25.8% in India [8], 17.2% in Pakistan [9], 26.2% in Malaysia [10] and 36% in Sri Lanka [11].

Adolescence is a time of significant changes in the domains of physical, psychological, social, and cognitive development [2, 12]. This period is stressful and may increase their vulnerability to several mental health problems if exposed to violence, abuse, or other stressful events [13]. Depression in adolescence is associated with substantial impairment in functioning and a greater likelihood of experiencing a major depressive episode and other psychiatric disorders in the future [14–16]. It is noteworthy that adolescent depression can impact the path of personality development potentially leading to impaired social functioning in adulthood [17–19]. It can lead to several risk-taking behaviors such as violence, drug and substance abuse, poor dietary habits, alcoholism, and even suicidal ideation among adolescents [20–23]. Thus, by preventing depression, we can protect adolescents from this vicious cycle of maladaptive behavior.

Despite being one of the major public health issues in developing nations, depression is often neglected and Nepal is no exception. According to the National Mental Health Survey of Nepal 2020, the prevalence of mental distress among adolescents is reported to be 5.2% [24]. The past studies focusing on depression among Nepalese adolescents suggest that the overall prevalence of depression among this vulnerable population range from 11.1% to 27% [25, 26]. A past study on depression among higher secondary school adolescents in Nepal by Bhattarai and colleagues [2] suggested a research gap notifying the possible relationship existing between psychosocial school environment and adolescents’ mental health in Nepal but didn’t explore the potential relationship and this study tries to address it. Considering this research gap, this study aimed to assess the prevalence of depressive symptoms and its associated factors among adolescent.

Methodology

Results

A total of 290 school-going adolescents were approached for data collection, out of which 271 provided complete response to all the questions. Thus, the response rate of 93.45% for all question was acquired and 271 samples were analyzed for this study. Among the 271 participants, 116 reported to have experienced depressive symptoms in past one week based on CES-D score >18, demonstrating the prevalence of depressive symptoms to be at 42.8%. (Table 1).

Out of 271 participants, nearly half of the participants were females (53.9%). The age of the participants in this study ranged from 12 to 19 years, with a mean age of 13.93±1.50 years. A large majority (77.5%) of the participants reported following Hinduism as their religion. The students from 8^th grade comprised of 38.5% of the total participants followed by 32.1% of them from 9^th grade and remaining 29.2% from 10^th grade. In regards to the academic variables, almost two-third (62.4%) of the adolescents perceived that they experience academic stress. Nearly half (56.1%) of the adolescents reported to have moderate level of perceived family support. More than half (57.9%) of the participants were noted to have moderate self-esteem. In context of their physical activeness, three-fifth (60.1%) of them reported to perceive themselves to have sedentary lifestyle. (Table 2).

The bivariate analysis performed through χ² test revealed the socio-demographic factors such as age and gender to have a statistically significant relationship with adolescent depressive symptoms at p<0.05. However, participant’s religion, family type, and parental education were not associated with depressive symptoms. A statistically significant relationship existed between adolescents’ depressive symptoms and their academic attributes such as academic level, type of school, perceived academic stress and satisfaction with academic performance. Similarly, adolescents’ level of perceived family support, problem sharing behavior, and level of self-esteem were also found to be associated with depressive symptoms. (Table 2).

For multivariate analysis, the VIF test was performed among independent variables found to have statistically significant relationship with depression in bivariate analysis, where the highest reported VIF was 1.840, indicating that there was no issue of multicollinearity. It was observed that female adolescents were twice (aOR: 2.309, 95%CI 1.233–4.325) more at odds of experiencing depression than male adolescents. Similarly, in comparison to adolescents enrolled in 8^th grade, there was two-folds increase in odds of depression among adolescents enrolled in 9^th grade (aOR: 2.420, 95%CI 1.091–5.365) and four-folds increase among adolescents enrolled in 10^th grade (aOR: 4.576, 95%CI 1.482–9.128). Likewise, students studying in private school were twice (aOR: 2.302, 95%CI 1.184–4.476) more at odds of experiencing depression as compared to adolescents studying in public schools. Similarly, adolescents not sharing problems with their friends were thrice (aOR: 3.022, 95%CI 1.477 to 6.186) more at odds of experiencing depression as compared to those who shared their problems with their friends. Also, it was seen that students experiencing academic stress had two-folds (aOR: 2.388, 95%CI 1.263–4.518) increase in odds of depression than who didn’t. Likewise, students experiencing dissatisfaction with current academic performance were twice (aOR: 2.278, 95%CI 1.141–4.518) more at odds of experiencing depression. Similarly, students having lower perceived family support were thrice (aOR: 3.440, 95%CI 1.276–9.275) more at odds of facing depression than who had higher perceived family support. Similarly, in comparison to adolescents having higher self-esteem, there was two-folds increase in odds of depressive symptoms among adolescents having moderate self-esteem (aOR: 2.009, 95% CI 1.017–3.969) and two-folds increase among adolescents having lower self-esteem (aOR: 2.139, 95%CI 1.061–8.708). (Table 3).

Discussions

The prevalence of depressive symptoms among adolescents studying in secondary school of Birtamod Municipality was found to be 42.8% which is near to the prevalence observed among higher secondary school adolescents of Pokhara Metropolitan city at 44.2%, using the CES-D tool for screening [2]. However, the current prevalence is slightly higher than the prevalence noted among secondary school adolescents of Kathmandu Metropolitan city, which was at 25.9% [32]. The prevalence of mental disorder among Nepalese adolescents of age 13–17 years was noted to be at 5.2% by the National Mental Health Survey of Nepal of 2020 [33]. Although the national average seems to be low, other cross-sectional studies conducted in different part of the country suggest that overall prevalence of depression among adolescents lies between 11.1% and 56.5% [25, 26, 28, 34, 35]. This difference in rate of depressive symptoms observed among Nepalese adolescents might be due to the difference in nature of the study area and the diverse social and ethnic characteristics of the country. This high prevalence of depressive symptoms highlights the raising concern of mental wellbeing among Nepalese adolescents.

The studies based on Southeast Asian (SEA) region also suggest an alarming rate of depression among the adolescents as 34.9% of the adolescents were reported to experience depression in Thailand [36], 33.1% in Malaysia [37], 29.3% in Indonesia [38] and 27.2% in Myanmar [39]. A study conducted among higher secondary school students of North Kerala, India reported that clinically significant depression lies as high as 57.7% [40]. This reveals that there is a high prevalence of depressive symptoms among the adolescents which is a raising public health concern.

In this study, the socio-demographic factors such as religion, family type, mother’s education were not found to have statistical association with depressive symptoms. These findings are in line with the findings shared by the study based on secondary level students of Kathmandu Metropolitan, observing no statistical relationship between these socio-demographic factors and depression [32]. Similar to the finding of this study, another study from Nepal revealed that female adolescents were almost twice more at odds of being depressed than their male counterparts [35]. Similar phenomenon has also been observed in other nations such as Malaysia and Central Uganda, where female were found to have almost two-to-three-folds increase in odds of depression than males [41, 42]. Female adolescents experience hormonal changes and stressful events during puberty much more than males, which might make them more prone to anxiety and stress [34]. The hormones such as estrogen and progesterone have been noted to affect different regions of brain such as hippocampus, thalamus and brain stem which are responsible for modulation of mood and behavior [43]. The fluctuation in these hormones has also been linked to premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) [44]. All of these might be the reason for the females adolescents to be more vulnerable to depressive symptoms than males.

This study noted that school environment and academic factors can have a major influence on adolescent’s mental health. The students enrolled at private schools were found to have higher odds of being depressed than those from public school. Similarly, higher the academic level of the students, higher was their odds of experiencing depressive symptoms. Similar observation was also shared by a past study from Northern India where private school students were found to have three-fold increase in odds of depression as compared to public school students [45]. In contradiction, another study from India noted the prevalence of depression and anxiety to be higher among adolescents of public schools, whereas the level of stress was observed to be higher among the private school adolescents [46]. Likewise, another study based on school going adolescent of India also noted that higher grade students were 1.6 times more likely to be depressed than students at lower grades [47]. The reason for the students from private schools and higher grades to be more depressed might be linked with higher level of stress, academic pressure and competitive environment.

It was observed that presence of perceived academic stress is one of the important factors linked with depressive symptoms. This is in line with the findings shared by a study based on urban Nepal where students who perceived higher academic stress were reported to have higher likelihood of experiencing mental distress [34]. Likewise, it was also observed that students who were not satisfied with their academic performance were more likely to be depressed than the students who were satisfied. In line with this study, another study from rural Nepal noted that those students who were not satisfied with academic performance were twice more likely to be depressed than those who were satisfied [26]. The academic stress and dissatisfaction with one’s own performance might lead the adolescents through feeling of inadequacy and overwhelming pressure to perform better, and might lower their confidence and self-esteem.

The psychosocial factors such as lower level of perceived family support, not sharing their problems with peers as well as lower level of self-esteem among the school adolescents were found to have a significant relationship with depressive symptoms. Another study from Nepal revealed the interconnection between perceived level of social support and individual’s self-esteem, suggesting that perceived social support could be affecting the mental health by affecting individual’s self-esteem [30, 48, 49]. It was also suggested that family members can be the primary factor influencing the person’s self-worth leading further towards higher self-esteem [30]. Similar observations were also made in other nations as Ethiopian adolescents with lower level of social support were found to be six times more likely to develop depression than those who had moderate level of social support [50]. Similarly, the Vietnamese students with lower self-esteem were nearly five times more likely to experience depression than those with higher self-esteem [51]. The negative correlation between mental distress and self-esteem has been well established among students group [30]. These findings suggest that since social support and self-esteem contributes significantly to the mental wellbeing of the students, screening for poor support system and low self-esteem can possibly be a good strategy to identify student’s risk of mental health problems as well as other social and behavioral problems.

Supporting information

Acknowledgments

We would like to thank all academic institutions and students who participated in this study, for their valuable time and information. Without them this study wouldn’t have been possible.