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Research Article
Revised

Depression, anxiety, and stress among urban and rural adolescents in Shivamogga, Karnataka

[version 3; peer review: 1 approved, 3 approved with reservations]
PUBLISHED 12 Jul 2024
Author details Author details
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REVIEWER STATUS

This article is included in the Manipal Academy of Higher Education gateway.

Abstract

Background

Currently there are 1.3 billion adolescents worldwide, which makes up 16% of the world population. Over 20% of adolescents around the world are thought to have behavioural or mental health issues. Addressing mental health issues is very important for the promotion of positive health in adolescents. This study aimed to estimate the prevalence of depression, anxiety and stress among adolescents in urban and rural areas of Shivamogga.

Methods

A cross-sectional study was conducted among 350 adolescents aged 16 to 19 years each from urban and rural areas of Shivamogga.

Results

Depression, anxiety and stress were found to be 23.1%, 29.4% and 26.6% in urban areas and 19.1%, 24% and 21.1% in rural areas respectively. Depression was more common among females in both urban and rural settings, with a significant difference observed in rural areas. Anxiety and stress were also more prevalent among females, with anxiety significantly higher in urban females. Urban adolescents exhibited higher levels of depression, anxiety, and stress compared to their rural counterparts.

Conclusions

About a quarter of the adolescent population suffers from depression anxiety and stress. Adopting and implementing better education and health policies are necessary to enhance adolescent mental health.

Keywords

Mental health, Adolescence, Depression, anxiety, stress

Revised Amendments from Version 2

The introduction has been comprehensively reviewed and strengthened.
The methodology section has been expanded to provide a more detailed information about assessing DAS.
Potential limitations of the study have been acknowledged in the strengths and limitation section.

See the authors' detailed response to the review by Indranil Saha
See the authors' detailed response to the review by Mohammad Meshbahur Rahman

Introduction

Currently, there are 1.3 billion adolescents worldwide, constituting 16% of the global population. 1 In regions like the South-East Asia region (SEAR) of the World Health Organization (WHO) and India, adolescents represent an even larger proportion, with percentages reaching 20% and 21.8% respectively. 2 , 3 This significant demographic is facing a critical challenge: over 20% of adolescents globally are believed to grapple with behavioural or mental health issues, with depression emerging as the leading cause of the global disease burden among this demographic. 4

Studies conducted in India and neighbouring countries highlight the alarming prevalence of depressive disorders among adolescents. For instance, in India, a staggering 40% of adolescents experience depressive disorders, while in Bangladesh, over 80% of college-going adolescents face moderate to severe levels of depression. 5 , 6 Additionally, anxiety disorders affect a significant portion of adolescents, with 3.6% of 10–14-year-olds and 4.6% of 15–19-year-olds experiencing such issues. 7 Stress is another factor that poses problems in adolescent life, with up to 61.5% of adolescents affected according to one study. Family conflicts and academic pressures are identified as the main triggers for stress among Indian adolescents. 8 , 9

Adolescence is a distinct period in human development and crucial for setting the groundwork for long-term health. 4 The consequences of untreated mental health conditions among adolescents are severe, ranging from decreased academic performance and attendance to hindered social relationships and reduced employment opportunities. 10 , 11 Moreover, depression significantly increases the risk of suicide, while smoking, substance abuse, and obesity are more prevalent among depressed adolescents. 12 14 Depressive disorders are among the top three causes of adolescent DALYs lost globally, and anxiety is among the top five causes of DALYs lost among adolescent girls. 15

Despite the evident need for intervention, there remains a dearth of research and data on mental health issues among adolescents in specific regions, such as Karnataka. Recognizing this gap, this study aims to estimate the prevalence of depression, anxiety, and stress among adolescents in urban and rural areas of Shivamogga taluk. By gathering more data and understanding the unique challenges faced by adolescents in this region, we can inform targeted interventions and promote positive mental health outcomes among this vulnerable population.

Methods

Ethics and consent

Ethical approval was granted by the Institutional Ethics Committee of Shivamogga Institute of medical Sciences, Shivamogga (ref no. SIMS/IEC/414) on 09/11/2018. Informed consent was taken from study participants and the parents/guardians in case of minors (16-17 years) via Google Forms. Assent was also taken from study participants of age 16-17 years.

Study design and data collection

A cross-sectional study was conducted from August 2020 to September 2020. The study population is composed of all adolescent males and females aged 16-19 years in rural and urban field areas of Shivamogga taluk.

Sample size estimation:

Sample size (n) = Z∞2pq/D2

Z∞ s standard normal deviate at the required confidence level (e.g. Z statistics: 1.96); d is the desired level of precision or level of statistical significance/margin of error the researcher accepts (e.g. 0.05); p is estimated characteristics of target population (variability of population parameters) the researcher assumes; and q is 1-p.

According to an Indian study, the prevalence (p) of anxiety among adolescents was found to be 24.4%. 16 With desired absolute precision of 5% the minimum sample size required was calculated using the formula Z∞2pq/D2. With this, we got a sample size of 295 adolescents. Considering 10% as non-respondents, the final sample size was 325 which was rounded off to 350. So, 350 samples were collected in urban and rural areas each.

The Block education officer was approached and a list of all pre-university colleges in Shivamogga taluk was collected. Shivamogga taluk has 36 pre-university colleges in the urban area and 10 pre-university colleges in the rural area. Then 50% of the pre-university colleges were randomly selected using the random number table both in urban and rural areas. So, 18 colleges from the urban and 5 colleges from the rural area were selected. From each selected colleges, a class was randomly selected. For each selected class the lottery method was used to select 20 students from each class in the urban area and 70 students from the rural area until the desired sample size was reached. All adolescents in the age group of 16 to 19 years were included in the study. Adolescents who did not fill out the questionnaire completely were excluded from the study.

After taking consent, a questionnaire that included basic demographic details (age and sex) with the DASS 21 scale (Depression Anxiety Stress Scale) 17 in the English without any translation or alteration was used to collect data. Given that English is the primary language of instruction at the PU college, we employed the scale without any need for translation. A Google Form of the questionnaire was created, one each for urban and rural areas and the link to fill out the form was shared with students willing to participate in the study via ‘WhatsApp’ mobile application. Adolescents aged 16 completed years and above until the age of 19 were included in the study.

The Depression, Anxiety, and Stress Scales (DASS) is a set of self-report measures designed to assess the emotional states of depression, anxiety, and stress. 17 Each scale provides a score that helps to determine the severity of these emotional states. The interpretation of these scores is based on cutoff values that classify the intensity of the symptoms into different categories: normal, mild, moderate, severe, and extremely severe.

Normal: Scores within this range indicate that the individual is experiencing a typical level of depression, anxiety, or stress, suggesting no significant symptoms in these areas.

  1. Depression: 0-9

  2. Anxiety: 0-7

  3. Stress: 0-14

Mild: Scores in this range suggest the presence of mild symptoms. While these might be noticeable, they typically do not cause significant impairment in daily functioning.

  1. Depression: 10-13

  2. Anxiety: 8-9

  3. Stress: 15-18

Moderate: Scores that fall within the moderate range indicate more pronounced symptoms that may affect daily life and functioning. Intervention may be beneficial.

  1. Depression: 14-20

  2. Anxiety: 10-14

  3. Stress: 19-25

Severe: Severe scores reflect substantial symptoms that are likely to impair an individual's ability to function in daily life. Professional help is often required.

  1. Depression: 21-27

  2. Anxiety: 15-19

  3. Stress: 26-33

Extremely Severe: Scores in this range indicate very intense symptoms that significantly interfere with daily functioning. Immediate and intensive intervention is usually necessary.

  1. Depression: 28+

  2. Anxiety: 20+

  3. Stress: 34+

Outcome measure:

The DASS consists of 21 items, divided into three self-reported subscales of seven items each, designed to measure depression, anxiety, and stress. Respondents rate each item on a 4-point Likert scale: 0 (“Did not apply to me at all”), 1 (“Applied to me to some extent, or some of the time”), 2 (“Applied to me to a considerable extent, or a good part of the time”), and 3 (“Applied to me very much, or most of the time”), reflecting their feelings over the past week. Each subscale's final score is doubled and assessed according to a severity rating index. The total scores for depression, anxiety, and stress are calculated by summing the values of all items in each of the three subscales, as detailed above.

Statistical analysis

Data was entered into a Microsoft Excel spreadsheet. SPSS (Version 21) was used to perform statistical analysis. Data analysis was done using appropriate statistical tools. Results were expressed in terms of frequency, percentages, Chi-square values, and P-values. All statistical tests were performed with a confidence level of 95% and a power of 80%. In the significance tests, P value equal to or less than 0.05 was considered as statistically significant.

Results

As shown in Table 1: a total of 700 adolescents participated in the study. Out of which 350 (50%) adolescents were from urban areas and another 350 (50%) adolescents were from rural areas. Males and females in urban areas were 153 (44%) and 197 (56%) respectively. In rural areas, males and females were 191 (55%) and 159 (45%) respectively.

Table 1. Distribution of study participants according to depression, anxiety and stressed in urban and rural areas. (n=700).

Sl. No.CharacteristicsUrbanRuralP value
1No. of participants0.004
• Males153 (44%)191 (55%)
• Females197 (56%)159 (45%)
2Age of the participants0.011
• 16 years94 (27%)60 (17%)
• 17 years142 (40.6%)159 (45%)
• 18 years100 (29%)121 (35%)
• 19 years14 (4%)19 (3%)
3Depression0.195
• Mild25 (7.1%)32 (9.1%)
• Moderate46 (13.1%)28 (8%)
• Severe10 (2.9%)7 (2%)
• Not depressed269 (76.9%)283 (80.9%)
4Anxiety0.105
• Mild29 (8.2%)21 (6%)
• Moderate71 (20.3%)58 (16.6%)
• Severe3 (0.9%)5 (1.4%)
• Not anxious247 (70.6%)266 (76%)
5Stress0.092
• Mild63 (18%)54 (15.4%)
• Moderate24 (6.9%)13 (3.7%)
• Severe6 (1.7%)7 (2%)
• Not stressed257 (73.4%)276 (78.9%)

All our study participants were aged between 16 to 19 years. the mean age of the participants in the urban area was 17.10±0.84 years. In the urban area, the majority of the participants (142) were aged 17 years (40.6%). Participants aged 16 years were 94 (27%), 18 years were 100 (29%) and 19 years were 14 (4%). Similarly in rural areas, the mean age of the participants was 17.10 ±0.76 years. The majority (159) of the participants were aged 17 years (45%). Participants aged 16 years were 60 (17%), 18 years were 121 (35%) and 19 years were 10 (3%).

Among the adolescents in urban areas, 23.1% were depressed, 29.4% had anxiety and 26.6% had stress. Similarly, among the adolescents in rural areas, 19.1% were depressed, 24% had anxiety and 21.1% were stressed.

Among the depressed adolescents, in urban areas the majority (46; 13.1%) had moderate depression, whereas in rural areas the majority (32; 9.1%) had mild depression. Among the adolescents who had anxiety, both in urban and rural areas the majority (71 (20.3%) and 58 (16.6%) respectively) had moderate anxiety. Among the adolescents who were stressed, both in urban and rural areas, the majority (63 (18%) and 54 (15.4%) respectively) had mild stress.

Among the study participants from urban areas of Shivamogga, 33 (21.6%) adolescent males and 48 (24.4%) adolescent females were depressed, 33 (21.6%) adolescent males and 70 (35.5%) adolescent females were anxious, and 55 (35.9%) adolescent males and 38 (19.3) adolescent females were stressed (see Table 2). A significantly greater number of females were anxious and stressed than males.

Table 2. Distribution of study participants based on sex in urban areas of Shivamogga (n=350).

Sl. No.CharacteristicsMalesFemalesP value
1Not depressed120 (78.4%)149 (75.6%)0.538
Depressed33 (21.6%)48 (24.4%)
2Not anxious120 (78.4%)127 (64.5%)0.005
Anxious33 (21.6%)70 (35.5%)
3Not stressed98 (64.1%)159 (80.7%)<0.001
Stressed55 (35.9%)38 (19.3%)

Among the study participants from rural areas of Shivamogga, 26 (13.6%) adolescent males and 41 (25.8%) adolescent females were depressed, 40 (20.9%) adolescent males and 44 (27.7%) adolescent females were anxious, and 47 (24.6%) adolescent males and 27 (17%) adolescent females adolescents were stressed. A significantly greater number of females were stressed than males; see Table 3.

Table 3. Distribution of study participants based on sex in rural areas of Shivamogga (n=350).

Sl. No.CharacteristicsMalesFemalesP Value
1Not depressed165 (86.4%)118 (74.2%)0.004
Depressed26 (13.6%)41 (25.8%)
2Not anxious151 (79.1%)115 (72.3%)0.167
Anxious40 (20.9%)44 (27.7%)
3Not stressed144 (75.4%)132 (83%)0.089
Stressed47 (24.6%)27 (17%)

Discussion

Our study attempted to find out the prevalence of depression, anxiety, and stress among adolescents in urban and rural areas. The current study found that the prevalence of depression was 23.13% and 19.14% in urban and rural areas respectively. On average, depression among adolescents in Shivamogga is 21.14%. Similar results were found by Kumar K S et al. and Sahoo S, where depression among adolescents was 19.5%. and 18.5% respectively. 16 , 18 Depression was seen to be higher in females in both urban and rural areas. The difference was statistically significant in rural areas of Shivamogga. Similar observations were made in other studies across India where depression was seen to be higher among female respondents. 16 , 19 , 20 Genetic predisposition and hormonal influences could be the reason why depression was higher in females than males. This could also be due to higher reporting of symptoms by females, whereas fewer males may report symptoms due to societal pressure for males to be more emotionally strong.

Depression was more frequently seen in urban adolescents than rural adolescents in the current study (23.1% and 19.4% respectively). Similar observations were made by Bahl R, and Kumari R in their study, where depression among urban adolescents was about 33.3% and depression among rural adolescents was 20.7%. 21 This could be due to higher exposure of adolescents to risk factors like academic competition and failure, anxiety, and substance abuse, etc.

Anxiety among adolescents in the current study was found to be 29.2% and 24% in urban and rural areas of Shivamogga respectively. On average, anxiety was found to be 26.6%. This was similar to the study conducted by Kumar K S et al. and Madasu S et al., who found anxiety among adolescents to be 24.4% and 22.7% respectively. 16 , 22 These studies also found that the prevalence of anxiety was higher among females when compared to males. Similar findings were seen in our study in both urban and rural areas. The prevalence of anxiety was significantly higher among females than males in urban areas. Higher anxiety among females could be due to higher exposure to risk factors like academic competition and societal pressure on women to work and prove themselves as equals to males in the modern world.

Anxiety was more frequently seen in urban adolescents than rural adolescents in our study (29.4% and 24% respectively). Similar results were observed by Vs P et al. 23 This could be due to more academic competitiveness in an urban area than in a rural area. While the parental expectation and societal pressure to perform better academically and excel in the future and have a well-paying job is higher for males than females, in the modern world the same pressure is higher in females as well in urban areas. This could be the reason why anxiety was more prevalent among urban females than males. As this study was conducted during the pandemic, the increased awareness of COVID in urban areas with better education could also be the reason why anxiety was higher among urban adolescents.

Stress among the adolescents in our study was found to be 26.6% and 21.1% in urban and rural areas respectively. On average 23.85% of the adolescents were stressed in Shivamogga. Sahoo and Saddicha, in their study, also found that the prevalence of stress among adolescents was 20%. 18 Prevalence of stress was found to be higher in urban areas compared to rural areas. Similar observations were made by Dey BK 24 in Bangladesh. No studies from the Indian setting could be found that compared the prevalence of stress in urban and rural areas.

Stress was more frequently seen in males than females in both urban and rural areas of Shivamogga. This was contrary to observations made in other studies, where they found that stress was more prevalent among female participants. 16 , 24 This difference could be due to underreporting of symptoms by female participants. The ongoing pandemic at the time of the study could have contributed to these findings.

Strengths and limitations

The strength of the study lies in its robust methodology, extensive sample size and comprehensive data analysis. This study employed a well-designed survey or assessment tool to gather data, ensuring the accuracy and reliability of the results. The measurement of depression, anxiety, and stress was conducted using a standardized scale rather than through assessment by a trained psychiatrist.

Factors affecting DAS were not investigated in our study. Future research should include an examination of these factors to provide a more comprehensive understanding of DAS.

While we ensured that the collected data is properly segregated into urban and rural categories based on the list of colleges obtained from the block education officer, it is worth noting that some participants from rural areas may commute and study in a college situated in urban areas, and vice versa.

Conclusions

About a quarter of the adolescent population suffers from depression anxiety and stress. It’s crucial to detect these symptoms among adolescents and take proper action to avoid compromising their education and development. Those detected to have these symptoms must be referred to be seen by a psychiatrist for clinical evaluation. Further studies are necessary to learn about the causative factors of these mental health disorders. Adopting and implementing better education and health policies are necessary to enhance adolescent mental health.

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Mallya A, Koppad R and Kumar P. Depression, anxiety, and stress among urban and rural adolescents in Shivamogga, Karnataka [version 3; peer review: 1 approved, 3 approved with reservations]. F1000Research 2024, 12:1583 (https://doi.org/10.12688/f1000research.139603.3)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
Version 3
VERSION 3
PUBLISHED 12 Jul 2024
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Reviewer Report 13 Jul 2024
Mohammad Meshbahur Rahman, Department of Biostatistics, National Institute of Preventive and Social Medicine, Dhaka, Bangladesh 
Approved with Reservations
VIEWS 6
The authors has improved the manuscript. But there are some additional comments that can improve the quality of the manuscript. 

1. In abstract, the methods section is still needs to improve. The sample size is 700 (350 ... Continue reading
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Rahman MM. Reviewer Report For: Depression, anxiety, and stress among urban and rural adolescents in Shivamogga, Karnataka [version 3; peer review: 1 approved, 3 approved with reservations]. F1000Research 2024, 12:1583 (https://doi.org/10.5256/f1000research.168246.r302320)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Reviewer Report 27 Jun 2024
Saranya Rajamanickam, PSG Institute of Medical Sciences & Research, Coimbatore, Tamil Nadu, India 
Approved with Reservations
VIEWS 4
Methodology:
1. Operational definition of dependent variable such as depression, stress and anxiety can be mentioned.
2. Type of sampling can be mentioned.
3. Need for separate google forms for urban and rural area can be explained.
... Continue reading
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Rajamanickam S. Reviewer Report For: Depression, anxiety, and stress among urban and rural adolescents in Shivamogga, Karnataka [version 3; peer review: 1 approved, 3 approved with reservations]. F1000Research 2024, 12:1583 (https://doi.org/10.5256/f1000research.164841.r287888)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Reviewer Report 24 Jun 2024
Rohith Motappa, Department of Community Medicine, Kasturba Medical College, Kasturba Medical College Hospital, Mangalore, Manipal Academy of Higher Education, Karnataka, Manipal, Karnataka, Manipal, 576 104, India 
Approved
VIEWS 5
This cross-sectional study aimed to assess the extent of depression, anxiety, and stress among adolescents residing in urban and rural areas of Shivamogga Taluk. Data was gathered over August and September 2020 through surveys involving 700 teens aged 16 to ... Continue reading
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Motappa R. Reviewer Report For: Depression, anxiety, and stress among urban and rural adolescents in Shivamogga, Karnataka [version 3; peer review: 1 approved, 3 approved with reservations]. F1000Research 2024, 12:1583 (https://doi.org/10.5256/f1000research.164841.r287883)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Reviewer Report 11 Jun 2024
Mohammad Meshbahur Rahman, Department of Biostatistics, National Institute of Preventive and Social Medicine, Dhaka, Bangladesh 
Not Approved
VIEWS 14
I want to thank the editor for inviting me to review the study. The sample size of this study is sufficient and the study design is appropriate. However, the study methods is not technically sound. The quire from the reviewer ... Continue reading
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Rahman MM. Reviewer Report For: Depression, anxiety, and stress among urban and rural adolescents in Shivamogga, Karnataka [version 3; peer review: 1 approved, 3 approved with reservations]. F1000Research 2024, 12:1583 (https://doi.org/10.5256/f1000research.164841.r287885)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 12 Jul 2024
    Ajay Mallya, Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India
    12 Jul 2024
    Author Response
    F1000 research article response
     
    • Comment: This was a very simple study where the authors just assessed DAS among 350 adolescents. There is a major limitation of demographic
    ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 12 Jul 2024
    Ajay Mallya, Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India
    12 Jul 2024
    Author Response
    F1000 research article response
     
    • Comment: This was a very simple study where the authors just assessed DAS among 350 adolescents. There is a major limitation of demographic
    ... Continue reading
Version 1
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PUBLISHED 14 Dec 2023
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Reviewer Report 23 Mar 2024
Indranil Saha, ICMR-Centre for Ageing and Mental Health (I-CAM), Indian Council of Medical Research, Kolkata, West Bengal, India 
Approved with Reservations
VIEWS 11
The manuscript needs following clarifications:
  1. “p-values less than 0.05 were considered significant” – please correct as p value equal to or less than 0.05 was considered as statistically significant
  2. As per rule the adolescents
... Continue reading
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CITE
HOW TO CITE THIS REPORT
Saha I. Reviewer Report For: Depression, anxiety, and stress among urban and rural adolescents in Shivamogga, Karnataka [version 3; peer review: 1 approved, 3 approved with reservations]. F1000Research 2024, 12:1583 (https://doi.org/10.5256/f1000research.152891.r257925)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 21 Jun 2024
    Ajay Mallya, Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India
    21 Jun 2024
    Author Response
    • Comment: “p-values less than 0.05 were considered significant” – please correct as p value equal to or less than 0.05 was considered as statistically significant
    Author’s Response: We agree ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 21 Jun 2024
    Ajay Mallya, Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India
    21 Jun 2024
    Author Response
    • Comment: “p-values less than 0.05 were considered significant” – please correct as p value equal to or less than 0.05 was considered as statistically significant
    Author’s Response: We agree ... Continue reading

Comments on this article Comments (0)

Version 3
VERSION 3 PUBLISHED 14 Dec 2023
Comment
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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