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Prevalence of students with symptoms of depression among high school students in a district of western Turkey: an epidemiological study.

Affective disorders, in particular depression, are one of the most common mental disorders with a lifetime prevalence of about 16%. (1) Between 8% and 18% of the population is estimated to have experienced at least 1 major depression episode during their lifetime. (2,3) Depression is also highly recurrent, with over 75% of patients experiencing more than 1 depressive episode. (4) Beck's cognitive theory of depression (5,6) and Abramson et al's (7) hopelessness theory of depression are the most influential theories in the field of depression. Many studies support the hypotheses proposed by these individuals into the existence of an interaction between cognitive vulnerability and stress that culminates in depressive symptoms. These studies also suggest that dysfunctional cognitions are not only a symptom of current depression; they seem to be trait like and persist beyond the remission of a current episode. Several recent prospective studies showed that individuals with such a cognitive vulnerability exhibit depressive symptoms when they experience negative life events. (8,9)

Depression is a key problem in terms of both society and mental health, knowing no cultural bounds. Reasons given for this are that it has a wide prevalence and carries a high suicide risk, affects quality of life negatively, and, as a result, contributes to medical, psychosocial, and family problems. (10,11) Early diagnosis for mental problems is also imperative, as are all manner of health problems, since depression sufferers show a full recovery if diagnosed and treated early. (3,9,11) Depression affects approximately 5% of today's teenagers (12) and is considered the fourth most important disease in the estimation of disease burdens. (13,14) The impact of adolescent depression on the individual and society is far reaching, as depression in teenagers has been found to significantly increase the risk of major depression and anxiety disorders, social dysfunction, nicotine dependence, alcohol dependence and abuse, educational underachievement, unemployment, early parenthood, suicide attempts, and completed suicide. (15)

Various studies conducted in Turkey have failed to address the question of the frequency of depression within the general population. It has been found in some regional studies, however, that the prevalence of depression was between 4.7% and 30%. (16, 17) Several studies have also shown that the prevalence of depression for adolescents was similar to that found in adults. (18, 19)

Adolescence is a transition from childhood to adulthood typically characterized by increased demands for coping with multiple social, biological, and psychological changes, as well as the emergence of the cognitive precursors of adulthood. (20) Most individuals emerge from adolescence are confident, with a healthy sense of whom they are and where they are heading. However, in some instances, the changes and demands of adolescence may leave a teenager feeling helpless, confused, and pessimistic about the future. Such adolescents are likely to become depressed. In its mild form, depression is the most common psychological disturbance among adolescents. (21,22)

This article presents data from a study of all the general high schools in a county of western Turkey, in a district of the city of Eskisehir called Sivrihisar. Several studies, conducted among selected target populations, have evaluated the prevalence of depression within Turkish society. (16,17) However, we are unaware of any earlier studies of depression conducted among high school students in Turkey, the specific aim of the present study. Consequently, the present cross-sectional study of depression sought to address several areas: the depression status of Turkish high school students, determination of some of the depression-related factors and the prevalence of depression among high school students in the target area, the assessment of the need for depression education, and the youths' sources of information concerning depression.

METHODS

Setting

Eskisehir is a semirural province situated in the western part of Turkey, with a population of about 705,000. The socioeconomic level of the city is average compared with other cities of the country. There are significant disparities in the socioeconomic characteristics of the quarters of the city. The city includes 2 universities and has a cosmopolitan structure. It has 6 small towns, 1 of which is Sivrihisar, in which the study was conducted. Sivrihisar has a total of 6 kinds of high schools called "the Health Professional High School," "the Sidika State High School," "the Girls Vocational High School," "the Imam-Cleric High School," "the Anatolian State High School," and "the Trade and Vocation High School."

Instrument

The questionnaire included information regarding the students' age, gender, place of residence, number of siblings, birth order in the family, the presence of any problem necessitating constant use of medication, the existence of any physical defect, the occurrence of previous bad experiences, any pocket money received from their family, and their mothers'/fathers' educational status.

Depression was measured with a Turkish version of the Beck Depression Inventory (BDI), (23) which consisted of 27 items. Adolescents were asked to choose 1 sentence from a group of 3 that best described their feelings within the past 2 weeks. High scores from the items indicated a higher incidence of depressive symptoms. The BDI, used as a screening test in this survey, was developed by Beck et al, (23) and later modified by Hisli, (24) to suit the Turkish culture and norms. The inventory has been widely used in various studies in Turkey, and it has been accepted that the Turkish version of the scale has sufficient reliability and criterion-related validity, including use with school students. (25)

The inventory was then pretested on a sample of 89 participants from different subpopulations of the high schools in small towns. The alpha coefficient for the internal consistency reliability of the items was found to be .83 for items concerning depression in the present study. The completed scales were checked for consistency and completeness. Items were marked using the options "0," "1," and "2." Responses to all the items were also converted to a percentage indicating the proportion of responses. The BDI was a self-administrated questionnaire administered as a face-to-face interview.

The answer for each item was evaluated as 0, 1, and 2 points. The lowest point was accepted as "0" and the highest point "54," with a cutoff point of 19. If a student had [greater than or equal to] 19 points, the student was accepted as at risk of depression based on other studies in Turkey. (24,25) School health teachers and school nurses were informed of those students who were identified as depressed or at extreme risk of self-harm, as well as information pertaining to and the participants' referral to psychiatry-related specialized centers. These precautions were performed for the protection of participants in terms of ethical standards.

Sampling

All 879 students surveyed were interviewed face-to-face between March and April 2006 for the present study. The dates on which the study would be conducted were determined in cooperation with school health teachers and school nurses in the schools concerned. They had been previously informed by the researchers about the aim of the study, filling in the questionnaire, and inventory. Due to the questionnaire being rather long, the survey being conducted on a general population, and there being a possibility that some students in the schools would not comprehend the questions, the researchers were on hand to explain any questions that the respondents found incomprehensible. Six schools situated in the city, each having approximately equal populations of students, were determined as the sample population. During the study period, a total of 846 students were studying in these schools. The study was conducted at the participants' schools. Our objective was to contact the entire population of subjects in the aforementioned places. Criteria for inclusion in the study were having the ability to complete the questionnaire and an education level of at least secondary school, working on the presumption that this would ensure that all participants had a basic knowledge level of depression, a basic level of maturity with regard to answering depression-related questions, or the ability to communicate with one another. Those who came to visit the schools from other cities and those who had not obtained permission from their parents were excluded from the study. In addition, those not present during the study and those not willing to participate were also excluded. The sample was representative of the total high school population.

Procedures

Groups of students at each school completed the questionnaires and inventories during a class period. After distributing the questionnaires to students at the schools, they were informed of how the questionnaires were to be filled in and then were requested to make a choice applicable to themselves. The students completed questionnaires and inventories in the presence of a member of the research team. The data collected were self-reported by the students.

All subjects (879, 100.0%) were told that participation in the investigation was strictly voluntary and that the data collected would not be used for anything except for this research study. Those who agreed to participate (846/879, 96.2%) were given the questionnaire and inventory to complete. The duration for completing the questionnaire and inventory was between 20 and 25 minutes per subject. The principal investigators met daily with the data collectors to ensure the quality of data collected.

Following the completion of the questionnaires and inventories, their body mass indexes (BMIs) were calculated by measuring their heights and weights. Those whose BMIs were 25 kg/[m.sup.2] and over were evaluated as overweight or obese. (26,27) Each student's body weight was measured with domestic scales and height with a meter rule. Students were also examined for the existence of acne vulgaris through physical inspection.

Legal Ethical Consent

Ethical permission for the study was obtained prior to collecting data by contacting and receiving approval from the appropriate management authority, the health directorships of the city and town involved. Participants were assured of the confidentiality of their responses and provided informed verbal consent. Assent was obtained from the students themselves. The students' parents received the informed written consent form given to the students by the researchers. The students also returned the forms whether consent was given or withheld.

Statistical Analyses

The Statistical Package for Social Sciences (SPSS) version 10.0 (Chicago, IL) was used to enter and analyze the data on a personal computer. Data were evaluated through frequencies, percentages, ratios, chi-square, and t tests. The measure for statistical significance was established a priority as p < .05.

RESULTS

Of the participants, 439 (51.9%) were boys and 407 (48.1%) girls. The average age of the participants was 16.3 [+ or -] 1.1 years (range = 14-19 years). There was no average age difference between boys and girls (16.2 [+ or -] 1.0, 16.3 [+ or -] 1.I, respectively). About one third of the students (30.2%) were from the Trade and Vocation High School, followed by the Anatolian State High School (22.5%). More than 80% of the students (86.5%) were in the age group of 17 and below or in their freshman or sophomore years of high school. Almost 100% (97.9%) were single. Most students had a nuclear family type (77.4%). The proportion of students whose mothers had been educated to primary school level and lower was 73.5%, with a figure of 38.7% for the same level in students' fathers. The majority of the students reported getting pocket money from their family (78.9%). The difference between the students' age distribution by their gender was not significant. There were no significant differences between males and females according to the descriptive information. More detailed general characteristics of those with and without depression are shown in Table 1.

The average BDI score of all the students was 15.61 [+ or -] 9.08, with the figures of 17.42 [+ or -] 9.31 and 13.88 [+ or -] 8.51 for female and male students, respectively (t = -5.75, df = 821.549, p < .001).

Depression was determined in 260 (30.7%) of 846 students with a mean age of 16.4 (SD = 1.0) and a mean age of 16.2 (SD = 1.1) for those without depression. An important difference was revealed by the scale between those who were depressed and those not depressed (t = -2.23, df = 515.495, p = .026). Of the students with depression, 99 (38.1%) were male and 161 (61.9%) female. There was no difference between the boys' and the girls' average depression scores (26.22 [+ or -] 7.41 and 26.80 [+ or -] 6.89, respectively).

More girls had depression compared to boys (39.6%, 22.6%, respectively), showing a significant gender difference in depression ([chi square] = 28.694, df = 1, p < .001). Those in the Girls Vocational High School and Health Professional High School (47.3%, 33.0%, respectively) had a higher rate of depression compared to those in other schools, namely Sidika State High School, Imam-Cleric High School, Industry-Vocational High School, and Anatolian State High School (35.3%, 29.5%, 26.3%, 22.6%, respectively) ([chi square] = 24.127, df = 5, p < .001). Although those with a patriarchal family type, a mother and father with educational levels of primary school or lower, and receiving pocket money from their family showed higher rates of depression compared to the other groups, the differences were not significantly different.

The students' depression status according to their individual characteristics is presented in Table 2. Depression was more common in those who had a physical defect (37.3%, 27.3%, respectively) ([chi square] = 9.113, df = 1, p < .05), had any chronic disease necessitating the use of any medicine (51.1%, 28.4%, respectively) ([chi square] = 19.487, df = l, p < .001), had previously experienced any bad event (47.3%, 22.5, respectively) ([chi square] = 54.452, df = 1, p < .001), and had acne vulgaris (35.2%, 26.8%, respectively) ([chi square] = 6.914, df = 1, p < .05) compared to others without those attributes.

DISCUSSION

To our knowledge, this is the first survey on depression in high school students conducted in a small district of Turkey. This survey allowed the assessment of the prevalence of depression in a sample of high school students from different types of schools.

Our results indicated that about 1 in 3 students (30.7%) had depression. Some studies in our country (28,29) reported that the prevalence of depression was found to be between 15.0% and 25.9%. In some studies on adolescents or high school students conducted in several other countries, (30,31) the prevalence of depression was observed at between 7.6% and 35.1%, results that were compatible with our study. One explanation for these differences in reported depression rates could be the inconsistency in how questions were asked regarding time frame. A further possibility could be connected to individuals' sociodemographic characteristics, such as age, education, and income, as well as lifestyle variables, such as drinking, smoking, and exercising. A further explanation may be that since there is a university exam taken after high school in our country, which is very stressful and governs the students' future, the preparation process for this exam may cause the student to have stress.

In our study, it was found that more girls had depression compared to boys. In a survey on adolescents conducted by Yavas et al (17) in Turkey, it was found that girls had a significantly higher rate of depression than boys. Furthermore, in many studies on depression in young people, the rate of depression was observed as higher in girls than in boys. (32,33) Some researchers also reported that girls were at a greater risk of depressive moods, feelings of low self-worth, and self-blame. (34) That depression was found to be higher in girls than in boys in many studies may indicate that girls in particular are at risk of depression. This may be due to the fact that girls are preparing to become women during the adolescence period and that they experience different constraints and psychological problems, along with having difficulty in expressing themselves during this period.

The proportion of students with depression was higher in the Girls Vocational High School than in the other schools. This may indicate that the students studying in this type of school may be at higher risk of depression. In other words, in a single-sex study environment, the fact that the students cannot interact with the opposite sex, in contrast to the other schools, may increase the level of anxiety or depression.

Although it has been reported in some studies (31-33) that the frequency of depression showed an increase with age, we did not find any such difference in this study. One explanation for this may be that the age range of our study group was rather limited because it was conducted only on students in high schools.

There was no relationship between the number of siblings or birth order in the family and the presence of depression. In Turkey, a study by Akin et al (35) reported that no relationship was observable between depression and the number of siblings.

The findings of this study suggest that the frequency of depression was not associated with the family structure type. This result is consistent with the findings of other studies. (35,36) In contrast, as expected, in a study by Cortese et al, (37) children with only 1 parent had higher levels of depressive symptoms. This may be explained by the fact that children and youths with 1 parent may be more likely to have a parent with mental health problems. Another reason may be that young people with 1 parent need to talk with someone about matters relating to depression.

There were no significant associations between the frequency of depression in students and their parents' educational levels, nor was there for frequency of depression and being in receipt of pocket money from their family. Similarly, in a study by Fleming and Offord, (36) it was demonstrated that there was no significant relationship between socioeconomic level and the frequency of depression. However, some studies have found that children of families whose socioeconomic level was low stood a higher risk of depression. (35,38) One explanation for these differences in results by socioeconomic level and depression could be that the scales used for determining socioeconomic level were not standard. It seems there is a need for further investigation into the role of socioeconomic level and prevention of depression, particularly in countries such as Turkey where socioeconomic levels vary considerably.

In the present study, the depression prevalence of students who were overweight/obese was lower than those who were normal weight. As in our study, Cortese et al (37) also showed that the relationship between BMI and prevalence of depressive symptoms was not significant. However, these findings are not concordant with the data reported by a study showing that depressive symptoms were higher in overweight/ obese students. (39) No apparent reasons were detected for such differences; it is possible that girls have more anxiety related to a desire to be thinner. (40) We commend that prospective studies on the relationship between overweight/obese and depression may identify important findings that would be useful. However, further studies are needed to better assess these issues.

In our study, those having a physical defect when compared to those without such a defect were at a significantly higher risk of depression. This may be explained by these individuals having an obsessive preoccupation with an imagined appearance defect and potential social rejection. (41,42) Students with a chronic disease that required the use of any medicine and any previous experience of disease had a significantly higher risk of depression when compared to those students who had not had these problems. These results are in concordance with the results of some studies. In these studies, it was shown that disease inflicted a significant burden on the daily physical activities of the patients, as well as on their schooling and job opportunities. In addition to these problems, these students were also insensitively teased by peers because of their typical features and that diseases had their own consequences on the students' social behavior in that they were more introverted. (43,44)

The students with acne vulgaris on their face in this survey had a significantly higher risk for depression compared to those who did not have acne. This rather high rate, peaking at a difference of 10%, was in line with results published by some researchers in Turkey as well as those of other countries. (45,47) By way of an explanation for this, it has been suggested that acne affects psychosocial health disparagingly due to the psychological issues attached to it, which include pain and discomfort, shame, body image, social assertiveness, obsessive-compulsiveness, embarrassment, and social inhibition. Furthermore, acne is also associated with a greater psychological burden than a variety of other disparate chronic disorders. (47,48)

Several important limitations should be considered in interpreting the results of our study. One of the limitations of this study was that it was cross-sectional, thus precluding inferences of casualty among variables. The second limitation is the self-reported nature of this survey.

Finally, the sample of the current study comprised a group of students in just 1 city of Turkey, which may limit generalization of the results. Thus, in order to definitively answer this question, a large sample containing different high schools in the region or country needs to be conducted.

Another limitation is that using the BDI is complicated with chronically ill people as several items of the BDI contain physical issues that are part of an illness and thus may not necessarily reflect depression.

Since this scale was used as a screening test, not a definite diagnosis, those who were at the risk of depression were not actually diagnosed with depression. The lack of sufficient time as well as an environment in which to conduct the interviews clinically were not available. Thus, those students at risk were referred to psychiatry-based specialized centers with the assistance of school health teachers and school nurses.

CONCLUSION

The frequency of students with symptoms of depression in high school students was relatively high throughout our study, reaching almost one third (30.7%). This indicates that there is a need for depression-related health education programs targeting those at higher risk such as those with a physical defect, a chronic disease necessitating the use of medicine, a previous bad experience, acne vulgaris, and females.

We recommend that formal information on depression be provided to families and teachers about depression and its symptoms and that each school's administration employs a psychologist or counselor who may prevent or deal with adolescent's psychological problems at an early age.

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ALAADDIN UNSAL, MD(a)

UNAL AYRANCI, MD(b)

(a) Associate Professor, (aunsal@ogu.edu.tr], Medical Faculty, Public Health Department, Osmangazi University, 26480 Meselik-Eskisehir, Turkey.

(b) Family Practitioner, (unalayrancioglu@yahoo.com), Medico-Social Center, Osmangazi University, 26480 Meselik- Eskisehir, Turkey.

Address correspondence to: Unal Ayranci, Family Practitioner, (unalayrancioglu@yahoo.com), Medico-Social Center, Osmangazi University, 26480 Meselik-Eskisehir, Turkey.

The author wishes to thank the schools' headmasters, teachers, and the study students for their valuable efforts and time.
Table 1. Sociodemographic Characteristics of Students by
Status of Depression

                                        Depression

                                 Yes, n (%),   No, n (%),   Total, n
Sociodemographics                260 (30.7)    586 (69.3)   846 (100.0)

Sex *
  Male                            99 (22.6)    340 (77.4)   439 (51.9)
  Female                         161 (39.6)    246 (60.4)   407 (48.1)
Age group
  15 and below                    56 (24.6)    172 (75.4)   228 (26.9)
  16                              84 (31.3)    184 (68.7)   268 (31.7)
  17                              84 (35.6)    152 (64.4)   236 (27.9)
  18 and over                     36 (31.6)     78 (68.4)   114 (13.5)
School type *
  Health Professional             32 (33.0)     65 (67.0)   97 (11.5)
    High School
  Girls Vocational
    High School                   52 (47.3)     58 (52.7)   110 (13.0)
  Sidika State High School        53 (35.3)     97 (64.7)   150 (17.6)
  Imam-Cleric High School         13 (29.5)     31 (70.5)    44 (5.2)
  Anatolian State High School     43 (22.6)    147 (77.4)   190 (22.5)
  Industry-Vocational
    High School                   67 (26.3)    188 (73.7)   255 (30.2)
Number of siblings
  No                              13 (32.5)     27 (67.5)    40 (4.7)
  1 or 2                          80 (26.6)    221 (73.4)   301 (35.6)
  3 or over                      167 (33.1)    338 (66.9)   505 (59.7)
Birth order in family
  First                          115 (31.3)    252 (68.7)   367 (43.4)
  Second and over                145 (30.3)    334 (69.7)   479 (56.6)
Family type
  Nuclear                        193 (29.5)    462 (70.5)   655 (77.4)
  Patriarchal                     67 (35.1)    124 (64.9)   191 (22.6)
Mother's educational level
  Primary school or below        193 (31.0)    429 (69.0)   622 (73.5)
  Secondary school or over        67 (29.9)    157 (70.1)   224 (26.5)
Father's educational level
  Primary school or lower        109 (33.3)    218 (66.7)   327 (38.7)
  Secondary school or over       151 (29.1)    368 (70.9)   519 (61.3)
Receiving pocket money
  from family
    Yes                          196 (29.3)    472 (70.7)   668 (78.9)
    No                            64 (36.0)    114 (64.0)   178 (21.1)

* Statistically significant at p < .001.

Table 2. Individual Characteristics of Students by Status
of Depression

                        Depression

Individual        Yes, n (%),   No, n (%),    Total, n (%),
Characteristics   260 (30.7)    586 (69.3)     846 (100.0)

Overweight/obese
  Yes              18 (29.5)     43 (70.5)       61 (7.2)
  No              242 (30.8)    543 (69.2)      785 (92.8)
Physical defect *
  Yes             109 (37.3)    183 (62.7)      292 (34.5)
  No              151 (27.3)    403 (72.7)      554 (65.5)
Any chronic disease necessitating the use of any medicine **
  Yes              46 (51.1)     44 (48.9)       90 (10.7)
  No              214 (28.4)    540 (71.6)      754 (89.3)
Any event being experienced previously **
  Yes             133 (47.3)    148 (52.7)      281 (33.2)
  No              127 (22.5)    438 (77.5)      565 (66.8)
Acne vulgaris on the face *
  Yes             139 (35.2)    256 (64.8)      395 (46.7)
  No              121 (26.8)    330 (73.2)      451 (53.3)

* Statistically significant at p < .01;
** statistically significant at p < .001
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Article Details
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Title Annotation:Research Article
Author:Unsal, Alladdin; Ayranci, Unal
Publication:Journal of School Health
Article Type:Clinical report
Geographic Code:7TURK
Date:May 1, 2008
Words:5515
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