[version 3; peer review: 1 approved, 3 approved with reservations]
No competing interests were disclosed.
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.
A cross-sectional study was conducted among 350 adolescents aged 16 to 19 years each from urban and rural areas of Shivamogga.
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.
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.
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.
Disability Adjusted Life Years
Depression Anxiety Stress scale
South East Asia Region
Statistical Package for Social Sciences
World Health Organization
Currently, there are 1.3 billion adolescents worldwide, constituting 16% of the global population.
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.
Adolescence is a distinct period in human development and crucial for setting the groundwork for long-term health.
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.
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.
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 (n) = Z∞ 2pq/D 2
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%.
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)
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.
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.
Depression: 0-9 Anxiety: 0-7 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.
Depression: 10-13 Anxiety: 8-9 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.
Depression: 14-20 Anxiety: 10-14 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.
Depression: 21-27 Anxiety: 15-19 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.
Depression: 28+ Anxiety: 20+ Stress: 34+
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.
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.
As shown in
| Sl. No. | Characteristics | Urban | Rural | P value |
|---|---|---|---|---|
| 1 | No. of participants | 0.004 | ||
| • Males | 153 (44%) | 191 (55%) | ||
| • Females | 197 (56%) | 159 (45%) | ||
| 2 | Age of the participants | 0.011 | ||
| • 16 years | 94 (27%) | 60 (17%) | ||
| • 17 years | 142 (40.6%) | 159 (45%) | ||
| • 18 years | 100 (29%) | 121 (35%) | ||
| • 19 years | 14 (4%) | 19 (3%) | ||
| 3 | Depression | 0.195 | ||
| • Mild | 25 (7.1%) | 32 (9.1%) | ||
| • Moderate | 46 (13.1%) | 28 (8%) | ||
| • Severe | 10 (2.9%) | 7 (2%) | ||
| • Not depressed | 269 (76.9%) | 283 (80.9%) | ||
| 4 | Anxiety | 0.105 | ||
| • Mild | 29 (8.2%) | 21 (6%) | ||
| • Moderate | 71 (20.3%) | 58 (16.6%) | ||
| • Severe | 3 (0.9%) | 5 (1.4%) | ||
| • Not anxious | 247 (70.6%) | 266 (76%) | ||
| 5 | Stress | 0.092 | ||
| • Mild | 63 (18%) | 54 (15.4%) | ||
| • Moderate | 24 (6.9%) | 13 (3.7%) | ||
| • Severe | 6 (1.7%) | 7 (2%) | ||
| • Not stressed | 257 (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
| Sl. No. | Characteristics | Males | Females | P value |
|---|---|---|---|---|
| 1 | Not depressed | 120 (78.4%) | 149 (75.6%) | 0.538 |
| Depressed | 33 (21.6%) | 48 (24.4%) | ||
| 2 | Not anxious | 120 (78.4%) | 127 (64.5%) | 0.005 |
| Anxious | 33 (21.6%) | 70 (35.5%) | ||
| 3 | Not stressed | 98 (64.1%) | 159 (80.7%) | <0.001 |
| Stressed | 55 (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
| Sl. No. | Characteristics | Males | Females | P Value |
|---|---|---|---|---|
| 1 | Not depressed | 165 (86.4%) | 118 (74.2%) | 0.004 |
| Depressed | 26 (13.6%) | 41 (25.8%) | ||
| 2 | Not anxious | 151 (79.1%) | 115 (72.3%) | 0.167 |
| Anxious | 40 (20.9%) | 44 (27.7%) | ||
| 3 | Not stressed | 144 (75.4%) | 132 (83%) | 0.089 |
| Stressed | 47 (24.6%) | 27 (17%) |
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.
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%.
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.
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.
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%.
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.
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.
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.
figshare: DASS.xlsx.
This project contains the underlying data file.
figshare: Questionnaire - Depression, anxiety, and stress among adolescents in Shivamogga, Karnataka.
This project contains the blank questionnaire.
Data are available under the terms of the
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 from both urban and rural). Therefore, revise the first sentence of the methods. In addition, please report the study time, questionnaire tool (DAS) in one sentence. Finally, report the data analysis and software use information in third and last sentence. The author can follow the Methods section of abstract of the paper of Das et al., 2023 [Ref-1].
2. The author reported that "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." This findings has wrongly interpreted. We can not compare the findings without performing inferential statistics like t-test, proportion z-test or regression. Therefore, this article needs expert statistical assistance. The authors can consult to a statistician to improve this part.
In the full-text article, the sample size estimation formula is not correctly reported. The authors can follow the Methods section of the work of Das et al. (2023) [ Ref-1] mentioned above.
3. The discussion of the manuscript still needs substantial improving.
I hope the above comments will help to improve the manuscript further.
Is the work clearly and accurately presented and does it cite the current literature?
Partly
If applicable, is the statistical analysis and its interpretation appropriate?
Partly
Are all the source data underlying the results available to ensure full reproducibility?
Partly
Is the study design appropriate and is the work technically sound?
Partly
Are the conclusions drawn adequately supported by the results?
Partly
Are sufficient details of methods and analysis provided to allow replication by others?
No
Reviewer Expertise:
Public Health, Global Health, Biostatistics, Epidemiology
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
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.
4. Scoring of depression, anxiety and stress to categorize it into mild, moderate an severe is not clear.
Result:
5. A table depicting the frequency of depression, anxiety and stress among the urban and rural area explaining the objective will be appreciated.
6. Significant p value can be highlighted in all the tables and the level of confidence interval can be written below each table.
Is the work clearly and accurately presented and does it cite the current literature?
Yes
If applicable, is the statistical analysis and its interpretation appropriate?
Yes
Are all the source data underlying the results available to ensure full reproducibility?
Yes
Is the study design appropriate and is the work technically sound?
Yes
Are the conclusions drawn adequately supported by the results?
Yes
Are sufficient details of methods and analysis provided to allow replication by others?
Partly
Reviewer Expertise:
NCDs,
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
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 19.
The results showed that these mental health issues were common in both urban and rural adolescents, with higher rates observed in urban areas. Females consistently showed rates across all mental health conditions.
The author should consider expanding on the following areas:
1. If a selected student was absent during the data collection, how was the situation handled to maintain the desired sample size? What specific steps were taken in such cases?
2. The author may include the implications of this study in the discussion.
3. The author may also include some additional limitations of the study.
Is the work clearly and accurately presented and does it cite the current literature?
Yes
If applicable, is the statistical analysis and its interpretation appropriate?
Yes
Are all the source data underlying the results available to ensure full reproducibility?
Yes
Is the study design appropriate and is the work technically sound?
Yes
Are the conclusions drawn adequately supported by the results?
Partly
Are sufficient details of methods and analysis provided to allow replication by others?
Partly
Reviewer Expertise:
Non-Communicable Diseases, Mental Health, Geriatrics, Tuberculosis.
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
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 are pointed out below:
1. This was a very simple study where the authors just assessed DAS among 350 adolescents. There is a major limitation of demographic variables in this study. There are many factors that affects DAS of adolescents.
2. The study just presented frequency distribution, and no inferential statistics has presented.
3. The abstract of the study is insufficient and lack of key information. In abstract, the authors reported their study objectives in methods section. But, it should be place at the end of Background/Introduction section. In the methods section, the authors should report about DAS 21 and its' computational ways, and appropriate statistical analysis.
4. The results section in abstract is incomplete. The author should report associated factors of DAS among adolescents.
5. In the main text, the writings of introduction is very poor. The author are requested to add the recent literature and statistics in the introduction, avoiding orphan paragraphs. The introduction would be sound if the author would report the DAS of adolescents in the similar socio-demographics in South-Asia. [Ref.: Siddik M, et al., 2024 [Ref- 1]; Mridha MK et al., 2021 [Ref- 2]; Singh MM, et al., 2017 [Ref-3]; Bhattarai D, et al., 2020 [Ref-4]]
6. The methods of the study is very poor. The sample size estimation formula should write appropriately. The should report the scaling and scoring techniques of DAS 21.
7. To enrich the Methods of the study, the authors are requested to follow any standard approach of writing Methods [e.g,. Haque M, et al., 2023 [Ref- 5]; Siddik M, et al., 2024 [Ref-1]].
8. In the results section, the authors are strongly recommended to add inferential statistics to identify the associated risk factors of DAS among adolescents.
9. The discussion should be revised according to the new results.
Is the work clearly and accurately presented and does it cite the current literature?
Partly
If applicable, is the statistical analysis and its interpretation appropriate?
Partly
Are all the source data underlying the results available to ensure full reproducibility?
Partly
Is the study design appropriate and is the work technically sound?
Partly
Are the conclusions drawn adequately supported by the results?
Partly
Are sufficient details of methods and analysis provided to allow replication by others?
No
Reviewer Expertise:
Public Health, Global Health, Biostatistics, Epidemiology
I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.
The manuscript needs following clarifications:
“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 As per rule the adolescents with completed 19 years should have been included as study participants Colleges situated in urban and rural area: whether urban college truly represent urban adolescents? There may be so may students from rural area studying in urban college and the vice versa may be true. How socioeconomic status was measured in both the colleges? Please edit the sample size formula – “n=4pq/D2” instead of 4, please mention as Z
∞
2. In which language this DASS 21 scale was used? Was it validated and reliable in that settings?
Is the work clearly and accurately presented and does it cite the current literature?
Yes
If applicable, is the statistical analysis and its interpretation appropriate?
Yes
Are all the source data underlying the results available to ensure full reproducibility?
Yes
Is the study design appropriate and is the work technically sound?
Yes
Are the conclusions drawn adequately supported by the results?
Yes
Are sufficient details of methods and analysis provided to allow replication by others?
Partly
Reviewer Expertise:
Epidemiology, Non-communicable disease, Mental health
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
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 with your comment. The suggested correction has been made.
Action Taken in the manuscript: The suggested correction has been made.
Comment: As per rule the adolescents with completed 19 years should have been included as study participants
Author’s Response: We agree with your comment. We would like to clarify that adolescents who have completed 19 years were included in the study.
Action Taken in the manuscript: we have mentioned that adolescents aged 19 years have included in the study in the methodology section.
Comment: Colleges situated in urban and rural area: whether urban college truly represent urban adolescents? There may be so may students from rural area studying in urban college and the vice versa may be true.
Author’s Response: In the data collection process, 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. However, we acknowledge that some participants may commute and study in a college that does not accurately represent the demography (urban and rural). This can be seen as a limitation of the study.
Action Taken in the manuscript: Necessary changes have been done in the strengths and limitation section.
Comment: How socioeconomic status was measured in both the colleges?
Author’s Response: We have not measured the socioeconomic status of the participants in the study.
Action Taken in the manuscript: As socioeconomic status was not included in the original study instrument we have not included it in the study.
Comment: Please edit the sample size formula – “n=4pq/D2” instead of 4, please mention as Z∞
2
Author’s Response: We agree with your observation.
Action Taken in the manuscript: Necessary changes have been done in the manuscript.
Comment: In which language this DASS 21 scale was used? Was it validated and reliable in that settings?
Author’s Response: DASS21 Scale was used in English in our study without any translation or alteration. As the students studying in PU college have English as their first language we used the scale without any translations. DASS21 scale in English is already validated among adolescents.
Action Taken in the manuscript: We have duly incorporated this information into the methodology section of the manuscript for clarity.