Moataz M. Abdel-Fattah, PhD
Epidemiology and Research Unit, Department of Preventive Medicine
Chief of Preventive Medicine Department
Al-Hada Armed Forces Hospital
P.O. Box: 1347
Taif, Kingdom of Saudi Arabia
Tel: +966 (2) 7541610 (ext. 2196)
Fax: +966 (2) 7541238
E-mail: mezo106@yahoo.com, mezo106@hotmail.com
Abdel-Rahman A. Asal, MD
Department of Psychiatry,
Al-Hada Armed Forces Hospital,
Taif, Saudi Arabia
Abstract
Hypothesis: Most studies of depressed mood and its correlates in adolescents have been conducted in Western countries. The present large scale epidemiological study was designed to assess the prevalence and pattern of depression in a secondary school sample of Saudi Arabia adolescents.
Methods: A Cross-sectional survey, using the Arabic Beck’s Depression Inventory (BDI), by a team consisting of a psychiatrist and psychologist has been conducted.
Participants: Secondary school students (n = 490, 306 males “62.4 %” and 184 females “37.6 %”) of age group from (16 to 20).
Results: The prevalence of depression according to the Beck Depression Inventory (CBDI) (cut-off point: 19) was 110 (22.4 %) as moderate (19-29), 36 (7.3 %) as severe (30-40), and 18 (3.7%) as very severe (> 40) in this study group, with a clear predominance prevalence of depression in girls than in boys (1.5 times).
Multivariate logistic regression analysis demonstrated that the most significant risk factors involved were: sex, birth order, history of psychiatric illness, history of relative loss, and familial history of chronic diseases. Factor analysis revealed that self criticalness, agitation, and loss of energy had the highest scores in the total sample. In the male subgroup, loss of energy, self criticalness, punishment feeling and agitation had the highest score while in the female subgroup, self criticalness, agitation, and crying had the highest scores.
Conclusion: Our findings provide gender differences in the prevalence and presentation of depressive symptoms. The experience of a stressful life events increase the risk of depression. Assessment using screening is recommended. The increased risk for the onset of depression in adolescents reinforces the importance of early recognition and intervention.
Keywords: Prevalence, risk factors, adolescents, Depression, Beck Inventory scale, Saudi Arabia
Introduction
Depression has been considered to be the major psychiatric disease of the 20th century.1 The World Health Organization identified major depression as the fourth leading cause of worldwide disease in 1990.2 Recent studies have shown that greater than 20% of adolescents in the general population have emotional problems and one-third of adolescents attending psychiatric clinics suffer from depression.3 Numerous outcome studies have documented several negative effects of depression.4-6
Major depression often appears for the first time during the teenage years, and early onset depression interferes with a child’s psychological, social, and academic functioning, placing him or her at greater risk for problems such as substance abuse and suicidal behavior.4-5 Significant changes in social functioning, the adolescent’s environment, and gender-differentiated social support concerning sexuality. These factors, as well as the experience of a severe life event have been significantly related to the onset of major depression in adolescence.7
Despite the host of new literature on depression in adolescence has appeared in the last decade. The magnitude of child and adolescent depression is clearly a major mental health problem.5 There have been several efforts to improve the early detection of depression and to develop programs to prevent and treat it as soon as possible.8
This study was undertaken to find out prevalence and pattern of depression among secondary school students in Saudi Arabia as well as to clarify the degree to which stressful life events lead to depression.
Material and methods
Study design: This study was conducted on two phases implemented at the same time from January to May, 2005 at Taif city, Saudi Arabia: 1) A cross-sectional study for a representative sample of high school students aiming at screening for depression using Beck Depression Inventory scale (BDI). 2) A case-control study aiming at looking for risk factors of depression based on a cut-off level of BDI scale (BDI scale of 19 was chosen as a cut-off point).
The research protocol has been approved by Research and ethics committee at Al-Hada Armed Forces hospital and an informed consent have been obtained from all participants in the study.
Study area: Taif “means encompassing” is a city located at 1700-2500 meters above sea level in the western mountains of Saudi Arabia (Hejaz area) with population of 885474 according to 2000 census.9
Sampling: There are 12 secondary schools (7 for males and 5 for females) in Taif (public and private). A two-stage stratified sample of 490 students from six out of 12 secondary schools in Taif was randomly selected for the study. The sample constituted approximately 15% of the secondary school population of 3267 students in all the secondary schools. In the first sampling stage, all 12 secondary schools were classified into four groups according to sex and socioeconomic level (categorized into male public, female public, male private and female private groups). Then, using the appropriate allocation method of sampling, two schools were randomly selected from the first two groups and one school was selected from the private schools (a total of six schools were selected). In the second sampling stage, six classes were selected randomly from each of the selected public schools and three classes from each of the private schools to represent the different grades (one to three). Thus, a total of 18 classes were included in the sample. Each class was considered to be a cluster, and all students in the selected classes constituted the target group of the present study.
Sample size: It was determined with the prior knowledge that the lowest prevalence rate of severe depression among this age group is approximately 5%. Allowing an error of 2.5% and level of significance (type I error) of 1 %, it was believed that a sample size of 490 was adequate to achieve a high degree of precision in estimating the true prevalence rate of severe depression in the target population. Therefore, on computing for 99% confidence limits and with 2.5% error bound, it yielded the required sample size of 486.
Study tool: The Beck Depression inventory scale (BDI), Arabic version,10 has been used for screening of depression among study population. It is a 21-item self-reported measure, has been one of the most widely used screening instruments for detecting symptoms of depression. It can be administered to assess normal adults, adolescents, and individuals with psychiatric disorders (13 years of age or older).11 It was designed to document a variety of depressive symptoms the individual experienced over the preceding week. Responses to the 21 items are made on a 4-point scale, ranging from 0 to 3 (total scores can range from 0 to 63).
A self-administrated questionnaire was utilized including information regarding sociodemographic characteristics, history of psychiatric illness, family history of psychiatric illness, chronic diseases, parental or relative loss, as well as history of debates.
Statistical analysis: Data was analyzed using SPSS 11.0 for windows. Bivariate data analysis was performed and the chi square test was used to test for the association between BDI scale and sex. The second step of analysis consisted of a logistic regression, where significant variables from the bivariate analysis, and other important categories (age and paternal marriage) were included in the model as independent variables and where the dependent variable was BDI scale <19 vs. ≥ 19. Another multiple regression analysis was applied upon the most significant variables, with total BDI score as the dependent variable to calculate the coefficient of determination (r2).
A correlation matrix for all variables of BDI scale was computed. Bartlett’s test of sphericity was performed to test the hypothesis that all-off diagonal terms of the matrix are zero. Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy was done. The value of (KMO) should be greater than 0.5 if the sample is adequate. Principal components factor analysis with varimax rotation has been performed to assess the factor structure of the scale on the total sample and by sex. Results The study included 490 secondary school students (306 males “62.4%” and 184 females “37.6%). Their age ranged from 16 to 20 with a mean of 17.3 ± 1.0 years.
Table 1 presents BDI score according to sex. Sex differences were significant with female students having higher scores than males (x2= 18.3, P=0.001). The mean total score for the BDI (n=409) was 15.20± 11.14. According to the cut off scores, 160 students (32.7 %) scored as normal (0-9), 166 (33.9 %) as mild (10-18), 110 (22.4 %) as moderate (19-29), 36 (7.3 %) as severe (30-40), and 18 ( 3.7%) as very severe (> 40).
Table (1): Distribution of the study population (n=490) according to their sex and Beck depression inventory (BDI) score
| BDI score |
Male (n=306) |
Female (n=184) |
|
Normal (0-9) |
118 38.6 |
42 22.8 |
|
Mild (10-18) |
98 32.0 |
68 37.0 |
|
Moderate (19-29) |
56 18.3 |
54 29.3 |
|
Severe (30-40) |
20 6.5 |
16 8.7 |
|
Very severe (>40) |
14 4.6 |
4 2.2 |
|
Range |
5-59 |
0-43 |
|
Mean±SD |
14.19±11.81 |
16.88±9.73 |
Table 2 shows BDI individual item mean scores and SDs for total sample and by sex. “Self criticism” had the highest score in both of the total sample and female subgroup and had one of the highest scores among males. In the total sample, self criticism, agitation, and loss of energy had the highest scores. In the male subgroup, loss of energy, self criticism, punishment feeling and agitation had the highest score while in the female subgroup, self criticism, agitation, and crying had the highest scores. The lowest scores, in the total sample and in both of the male and female subgroups, were for loss of interest in sex, suicidal thoughts or wishes, and self dislike.
Female students had significantly higher scores than male students for the items sadness, punishment feelings, self criticism, crying, agitation, indecisiveness, loss of energy, changes in sleeping pattern, and concentration difficulty while male students had significantly higher scores than female students for the items loss of interest in sex, and loss of interest.
According to the BDI factor analysis for the total sample, the first unrotated factor accounted for 28.9% of the variance, and the second accounted for 6.7% of additional variability. Kaiser-Meyer-Olkin (KMO) measure for sampling adequacy was 0.88, a value that considered high and desirable. Chi square value of Bartlett’s test of sphericity was 2732.2, P<0.0001. When we considered loadings greater than 0.40 (when 2 loadings were similar, the item was considered to be part& both factors; when different, the highest loading was chosen), principal component analysis with varimax rotation suggested that the BDI factors that could be extracted were related to the following item: for factor 1, item 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 13, 14, 17, 18, 20, 21, and for factor 2, items 1, 4, 8, 10, 11, and 16. Based on the items related to factors 1 and 2, Cronbach‘s alpha coefficients for the subscales were 0.78 and 0.43, respectively.
Factor 1 represents the cognitive-affective dimension, while factor 2 represents items more related to a somatic nonspecific dimension.
Two factors from the factor analysis for the female’ subgroup were extracted (unrotated factors accounted for 23.09 % and 8.97 % of the variance, respectively). Principal component analysis with varimax rotation shoed that the factors were related to the following items: for factor 1, items 1, 3, 4, 5, 7, 8, 9, 10, 13, 14, 16, 17, 18, 20, and 21; and for factor 2, items 1, 4, 8, 10, 11, 16, and 18 (Cronbach’s alpha coefficients for the subscales were 0.82 and 0.31, respectively).
Also, two factors for the male’ subgroup were extracted (accounting for 33.24 % and 6.95% of the variance, respectively). Principal component analysis with varimax rotation suggested that they were related to the following items: for factor 1, items 1, 2, 3, 5, 7, 9, 10, 11, 13, 14, 15, 16, 17, 18, 19, 20, and 21; and for factor 2, items 4, 6, 8, 10, 11, and 16 (Cronbach’s alpha coefficients for the subscales were 0.75 and 0.59, respectively).
Among examined risk factors for depression, significant factors in bivariate analysis were: sex, birth order, number of brothers7, history of psychiatric illness, history of relative loss, and familial history of chronic diseases Table 4. In Multivariate analysis Females were 1.5 times more likely to have depression than males. First birth order students and those in between birth order (between first and last) were less likely to have depression than last birth order students. Students with history of psychiatric illness were 7.5 times more likely to have depression than those without history of psychiatric illness. Families with history of chronic diseases were 2.4 times more likely to have students with depression as compared to those without this history. The prevalence of depression was significantly higher among students with a history of loss of relative than among those without history of relative loss. Depressed students showed no significant differences from non-depressed students as regards number of brothers.
The combined effect of the five most significant variables, i.e. sex, birth order, history of psychiatric illness, history of relative loss, and family history of chronic diseases, was examined by means of multiple regression analysis with BDI score as the dependent variable. They jointly contributed 36.6% of the variance in the total score.
Discussion
Many researchers believe that mood disorders in children and adolescents represent one of the most under diagnosed group of illness in psychiatry. This is due to several factors: (1) children and young adolescents are not always able to express how they feel, (2) the symptoms of mood disorders take on different forms in adolescents than in adults, (3) mood disorders are often accompanied by other psychiatric disorders which can mask depressive symptoms, and (4) many physicians tend to think of depression and bipolar disorder as illness of adulthood.12 A recently published longitudinal prospective study found that early-onset depression often persists, recurs, and continues in to adulthood, and indicates that depression in youth may also predict more severe illness in adult life.13
There have been several efforts to improve the early detection of depression and to develop programs to prevent and treat it as soon as possible.14
In the current study, the BDI have been utilized to detect the prevalence of depressive symptomatology and its expression in a no clinical adolescent student sample. Although it is not designed for diagnostic purposes, its epidemiologic utility has been evaluated in several studies, which concluded that it is a reliable and valid instrument for detecting depressive disorders in non-clinical populations. Several studies support the BDI’s usefulness in measuring and predicting depression in adolescent samples.15-16 The scale’s format is clear; it is simple to administer; and it is easily understood by this population.17
Prevalence rates of actual depression are estimated to range from 15 to 25 percent.18 In our study which considered, up to our knowledge, the first study of this kind, in this area and according to the Beck cut off scores, about one third of the sample has moderate to severe depression and about 11% has severe to very severe depression. Comparable findings have been reported by others; the 1986 study of Minnesota high school students revealed that 39 percent suffer from mild to severe depression and nine percent of high school students are severely depressed.19 The lifetime prevalence of major depression in adolescents and young adults (15—24 years of age) in the United States general population has been reported as 20.6% for females and 10.5% for males (Kessler et al., 1998).20 Cubis (1989) reported that Around 20 per cent of young people suffer from depressed mood, with up to 43 per cent reporting feeling sad for at least two weeks in the past year.21 Lewinsohn, Rohde et al (1998) found that approximately 28% of adolescents will have experienced a major depressive episode by age 19 (35% of young women and 19% of young men).22 Another epidemiological study has reported that up to 8.3% of adolescents in the US suffer from depression.5
An NIMH-sponsored study of 9 to 17-year-olds have estimated that the prevalence of any depression is more than 6% in a 6-month-period, with 4.9% having major depression.23 Also, epidemiological utility and characteristics of the Beck Depression Inventory (BDI) were examined in a sample of 304 non-clinical adolescents in Indian schools and revealed that 22.4% of school going girls and 12.8% of school going boys had depression of various grades.24
Rutter, (1986a), suggest a variety of explanations for increasing prevalence of depression at adolescence age and that increasing level may be genetically determined and these genes triggered at late childhood or adolescence.25
In accordance with Jimerson et al who indicated that single risk factors can rarely be conceived as resulting in depressive outcomes. Instead, the biological, psychological, and social systems may be considered within a larger framework for explaining the etiology of depression.26 Our findings proved that more than one etiological perspective are associated with depressive outcomes. The sex differences found in BDI scores, pointing to significantly higher scores for female subjects (1.5:1 ratio), are in line with data observed in other studies of adolescents as well as adults.11, 27 Community studies showed that, for girls, there is a progressive rise in depressive symptoms from menarche, so that by the mid-teens girls exhibit at least twice the prevalence rate of males.28, 29 The finding that of female students, in contrast to of male students, had scores compatible with depression also agrees with reports of a higher prevalence of depression in women.30-31
Also Birmaher et al, reviewed the literatures published over the last decade on issues pertaining to early onset depression.5 These authors noted MDD is twice more common in females than in males during their adolescent years. One study reported even more dramatic gender differences for adolescent depression finding that girls were four times more likely to suffer from depression than boys (base rates were 13% and 4%, respectively).32 The cause of this striking rise in the incidence of depressive symptoms in adolescent females is as yet unknown, but hypotheses include the influence of female gonadal hormones, psychological changes that accompany puberty and changes in social roles.
The interaction of genetics and environment are strongly implicated in the onset of MDD. 26 In our study it is found that Students with history of psychiatric illness were 7.5 times more likely to have depression than those without history of psychiatric illness. Kandel et al reported that Adolescents with depression are also likely to have a family history of depression.33
There has been a tremendous body of literature that has demonstrated that mood disorders occur more commonly among the relatives of depressed persons than in the general population. In a review of longitudinal data it was estimated that, by the age of 20 years, a child with an affectively ill parent has a 40% chance of experiencing an episode of major depression.8 Based on a study of pubertal twins, there is evidence of increased heritability for depression in adolescent girls.34
According to Kaslow et al,6 family variables associated with depression are parental psychopathology, divorce, low SES, negative life circumstances including loss, abuse, or neglect, and low levels of social support. In our study, it was found that Parental loss among adolescents less significant than the effect of relative (loved one) loss and this may be unique in this kind of cultures and may be due to the predominance of extended families and remarriage. Wells et al,35 reported that loss of a parent or loved one is one of the important risk factor for developing depression among adolescents and this finding is in agreement with our finding.
In agreement with another study, 19 high school students revealed that Serious illness or injury of family member is one of the most common risk factor for developing depression among adolescents.
It is reported that siblings play a role in the development of depression, as problematic sibling relationships have been associated with greater depression, and a positive sibling relationship may mediate depression.26 Kingdom of Saudi Arabia (KSA) is on e of the unique countries to study the effect of sibling on depression as most of the families have many siblings so their effect should be handled. The 1986 study of Minnesota high school students revealed that trouble with brother or sister is one of the most common risk factor for developing depression among adolescents.19 Also, in KSA culture men may have more than one wife so it is important to study the role of remarriage in adolescents. It is found in our study that their effect is minimal and this may be explained on the basis of that most of the adolescents are sharing the social circumstances that lead to dissolve its stigmatizing effect and also and more important that it is well accepted form the religious and culture point of view. Conclusively, since many different factors can lead to psychopathology for different individuals and the etiology of a given disorder is perhaps best understood by looking at the interaction or transaction between these multiple variables over time.7
There is general agreement that the clinical features of depression are more similar than different in adolescents and adults, with the exception of a higher frequency of irritable mood in the adolescent presentation. Research suggests that women more frequently present with somatic symptoms of depression (i.e. fatigue, appetite and sleep disturbance, and body aches), which has been linked to the onset of major depression in early adolescence.36
Negative body image, low self-esteem, and recent stressful events have been highly correlated with depression in samples of high school students.37, 38 Compared with depressed boys, depressed girls more frequently exhibit problems with poor self-esteem, worthlessness, guilt feelings, and suicidal ideation.22, 39 Low social support has also been correlated with depression in girls.22 In the current study, factor analysis shows different symptom pattern between sexes.
In our study total sample, self criticism, agitation, and loss of energy had the highest scores. This finding is in agreement with Beck views about depression who associates depression with “low self-esteem, high self-criticism, significant cognitive distortions, and a feeling of lack of control over negative events.5 Our findings also are in agreement with Bennett and others who stress the importance of negative self-attitude and somatic symptoms in a sample of 328 adolescents with depressive and (or) anxiety disorders.16
Also, Chartier and Ranieri, (1984),40 reported that One-half to two-thirds of depressed adolescents, both inpatients and outpatients, complain of fatigue and lack of energy. Similarly, Weiner, (1980),41 reported that early adolescents are more apt to exhibit the following triad of symptoms: fatigue, hypochondria, and concentration difficulty. This is accepted form the cultural point of view due to the authoritarian effect of society with its burden on people in general and on adolescent in particular. This authoritarian effect takes different patterns such as religion, family and school (teachers). This also can explain the increase level of punishment feeling and somatizatoin level (loss of energy and agitation) among both sexes that allow less expression of feeling in appropriate way. The increase level of sadness and crying in female group than in male group could be explained by the fact that crying is more accepted among females than males as in males it means weakness of their personalities. This finding also reported in different studies.28
In contrast to others,42 our findings failed to prove an association between lower levels of paternal occupation and maternal education and occupation with elevated depression. Our findings, in agreement with another study,19 revealed that change in parents’ financial status is one of the most common risk factor for developing depression among adolescents.
Conclusively, our results indicate a high rate of depression among high school students. Also findings provided gender differences in the prevalence and presentation of depressive symptoms. The findings suggest that the experience of a stressful life events increase the risk of depression. Assessment using screening is recommended. The increased risk for the onset of depression in adolescents reinforces the importance of early recognition and intervention.
Acknowledgments
The authors would sincerely like to thank Miss Randa, Psychologist at Al-Hada Armed Forces hospital, for her assistance in data collection. Thanks are also due to the schoolteachers involved in the study and to Dr. Shugat Barni, consultant of Psychiatry,
Al-Hada Armed forces hospital, for revising the text.
Tables
Table (2): Beck Depression Inventory mean and SD scores according to sex
|
|
Total sample |
Female students |
Male students |
P-value |
|||
|
|
Mean |
SD |
Mean |
SD |
Mean |
SD |
|
|
1.Sadness |
0.74 |
0.82 |
0.84 |
0.90 |
0.68 |
0.77 |
0.040 |
Table (3): BDI items factor loadings after varimax rotation for the total sample and according to sex
|
|
Total sample |
Female students |
Male students |
|||
|
|
Factor 1 |
Factor 2 |
Factor 1 |
Factor 2 |
Factor 1 |
Factor 2 |
|
1.Sadness |
0.484 |
0.465 |
0.433 |
0.511 |
0.540 |
0.376 |
Table (4): Risk Factors for Depression According to Beck Depression Inventory (BDI): Bivariate Analysis
|
Characteristic
|
BDI |
Crude OR
|
95% CI
|
|||
|
<19 |
≥ 19 |
|||||
|
Sex |
216 |
70.6 |
90 |
59.8 |
1.0 |
1.10-2.37* |
|
Age in years |
296 |
67.6 |
142 |
32.4 |
1.0 |
0.85-2.75 |
|
Birth order |
8 |
33.3 |
16 |
66.7 |
1.0 |
0.07-0.61* |
|
Number of brothers |
58 |
55.8 |
46 |
44.2 |
1.0 |
0.30-0.79* |
|
Paternal occupation |
66 |
63.5 |
38 |
36.5 |
1.0 |
0.70-2.37 |
|
Maternal occupation |
288 |
66.4 |
146 |
33.6 |
1.0 |
0.48-2.02 |
|
Paternal education |
74 |
74.0 |
26 |
26.0 |
1.0 |
1.07-4.86 |
|
Maternal education |
120 |
68.2 |
56 |
31.8 |
1.0 |
0.63-1.95 |
|
Paternal-maternal relationship |
298 |
66.5 |
150 |
33.5 |
1.0 |
0.51-1.94 |
|
Paternal marriage |
250 |
68.3 |
116 |
31.7 |
1.0 |
0.89-2.08 |
|
Number of marriages |
52 |
65.4 |
28 |
34.6 |
1.0 |
0.71-4.86 |
|
Parental loss |
304 |
67.3 |
148 |
32.7 |
1.0 |
0.76-2.93 |
|
Age at parental loss |
13 |
68.4 |
6 |
31.6 |
1.0 |
0.64-9.03 |
|
Relative loss |
298 |
68.0 |
140 |
32.0 |
1.0 |
1.02-3.26* |
|
Psychiatric illness |
322 |
68.5 |
148 |
31.5 |
1.0 |
2.86-26.48* |
|
Family history of |
298 |
66.2 |
152 |
33.8 |
1.0 |
0.42-1.70 |
|
History of family |
308 |
68.8 |
140 |
31.3 |
1.0 |
1.54-5.58* |
|
Debates |
278 |
68.1 |
130 |
31.9 |
1.0 |
0.93-2.46 |
Table (5): Results of the multiple logistic regression analysis * of factors affecting Beck Depression Inventory scale (BDI)
| Independent variables |
B |
Standard |
P value |
OR |
95%CI |
|
Sex |
- |
- |
- |
1.00 |
- |
|
Birth order |
- |
- |
- |
1.00 |
- |
|
History of |
- |
- |
- |
1.00 |
- |
|
Family history of |
- |
- |
- |
1.00 |
- |
|
Relative loss |
- |
- |
- |
1.00 |
- |
Multiple r=0.605, r2 =0.366, adjusted r2= 0.290, SE= 7.65, F=4.77, P=0.004
® = Reference category
OR: Odds ratio
CI: Confidence intervals
References
1. Murphy JM, Monson RR, Olivier DC, et al. Affective disorders and mortality: A general population study. Arch Gen Psychiatry 1987; 44:473-480.
2. Murray CJL, Lopez AD. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990, and projected to 2020. Cambridge MA: Harvard University Press, 1996.
3. Kovaks M. Affective disorders in children and adolescents. Am J Psychol 1989; 44(2):209, 1989.
4. Hammen C, Compas BE. Unmasking unmasked depression in children and adolescents: The problem of co morbidity. Clinical Psychology Review. 1994; 14: 585-603.
5. Birmaher B, Ryan ND, Williamson DE, Brent DA. Childhood and adolescent depression: A review of the past 10 years, Part I. Journal of the American Academy of Child and Adolescent Psychiatry. 1996; 35, 1427-1439.
6. Kaslow NJ, Deering CG, Racusin GR Depressed children and their families. Clinical Psychology Review. 1994; 14, 35-59.
7. Cicchetti D, Toth S. The Development of Depression in Children and Adolescents. American Psychologist. 1998; 53 (2): 221-241.
8. Beardslee WR, Versage EM, Gladstone TR (1998): Children of affectively ill parents: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry. 1998; 37:1134-1141.
9. The Central Department of Statistics, Kingdom of Saudi Arabia, 12th issue (1423H – 2003).
10. Abdel-Khalek AM. Internal consistency of an Arabic Adaptation of the Beck Depression Inventory in four Arab countries. Psychol Rep 1998; 82(1):264-266
11. Beck A, Steer R, Brown G. BDI-II Manual. San Antonio: The psychological Corporation, Harcourt Brace. 1996.
12. Anne Brown MD, Mood Disorders in Children and Adolescents, NARSAD Research Newsletter, winter 1996.
13. Weissman MM, Wolk S, Goldstein RB, et al. Depressed adolescents grown up. J Am Med Association 1999; 281: 1701-1713.
14. Parker G, Roy K. Adolescent depression: a review. Aust N Z J Psychiatry. 2001; 35:572–80.
15. Barrera MJr, Garrison-Jones CV. Properties of the Beck Depression Inventory as a screening instrument for adolescent depression. J Abnorm Child Psychol. 1988; 16:263–73.
16. Bennett DS, Ambrosini PJ, Bianchi M, Barnett D, Metz C, Rabinovich H. Relationship of Beck Depression Inventory factors to depression among adolescents. J Affect Disor. 1997; 45:127–134.
17. Teri L. The use of the Beck Depression Inventory with adolescents. J Abnorm Child Psychol. 1982; 10:277–284.
18. Horn MP. Competence in daily living: A study of children and adolescents at risk for depression. Paper presented at the Biennial Conference for the Society for Research on Child Development, Seattle, WA, 1991.
19. Garfinkel B, Hoberman H, Parsons J, and Walker J. Adolescent Stress, Depression and suicide: Minnesota study (1986). Unpublished raw data. Joyce Walker, the Center for 4-H Youth Development, 2002 Regents of the University of Minnesota.
20. Kessler RC, Walters EE. Epidemiology of DSM-III-R major depression and minor depression among adolescents and young adults in the National Co-morbidity Survey. Depress Anxiety. 1998; 7:3-14.
21. Cubis J, Lewin T, Dawes F. Australian adolescents’ perceptions of their parents. Aust N Z J Psychiatry 1989; 23:35-47.
22. Lewinsohn PM, Rohde P, Seeley R. Major depressive disorder in older adolescents: Prevalence, risk factors, and clinical implications. Clinical Psychology Review. 1998; 18, 765-794.
23. Shaffer D, Fisher P, Dulkan MK, et al. The NIMH Diagnostic Interview Schedule for Children version 2.3 (DISC – 2.3): description, acceptability, prevalence rates and performance in the MECA study. J Am Academy of Child and Adolescent Psychiatry. 1996; 35(7): 865-877.
24. Nair MK, Paul MK, John R. Prevalence of depression among adolescent Indian J Pediatr. 2004; 71:523-524.
25. Rutter M. Depressive feelings, cognitions, and disorders: A research postscript. In M. Rutter, C. E. Izard, & P. B. Read (Eds.), Depression in Young People: Developmental and Clinical Perspectives, New York: Gilford Press, 1986a, pp. 491-519.
26. Shane R. Jimerson, Ashley Duggan, Angela Whipple and Jeffrey K. Ellens. Depression; symptoms, epidemiology, etiology, assessment, and treatment. Edited by Shane R. Jimerson, University of California, Santa Barbara, www.education.ucsb.edu/netshare/jimerson/dep.html, 2002.
27. Olsson G, Von Knorring AL. Beck’s Depression Inventory as a screening instrument for adolescent depression in Sweden: gender differences. Act Psychiat Scand. 1997; 95:277–82.
28. Clarice Gorenstein, Laura Andrade MD, Elaine Zanolo, Rinaldo Artes. Expression of Depressive Symptoms in a Non clinical Brazilian Adolescent Sample. Can J Psychiatry. 2005; 50:129–137
29. Angold A, Costello EJ, Worthman CM. Puberty and depression: the roles of age, pubertal status and pubertal timing. Psychol Med. 1998; 28:51–61.
30. Lehmicke N, Hicks AH. Relationship of response-set differences on Beck Depression Inventory scores of undergraduate students. Psychol Rep. 1995; 76:15–21.
31. Andrade L, Walters EE, Gentil V, Laurenti R. Prevalence of ICD-10 mental disorders in a catchment area in the city of Sao Paulo, Brazil. Soc Psychiatry Psychiatr Epidemiol, 2002; 37:316–25.
32. Kashani JH, Carlson GA, Beck NC, Hoeper EW. Depression, depressive symptoms and depressed mood among a community sample of adolescents. American journal of psychiatry 1987; 144:931-934.
33. Kandel D, Davies M. Epidemiology of depressive mood in adolescents. Archives of General Psychiatry. 1982; 39, 1205-1212.
34. Silberg J, Pickles A, Rutter M, et al. The influence of genetic factors and life stress on depression among adolescent girls. Arch Gen Psychiatry. 1999; 56:225-232.
35. Wells VE, Deykin EY, Klerman GL. Risk factors for depression in adolescence. Psychiatric Development, 1985; 3(1):83-108.
36. Silverstein B. Gender differences in the prevalence of clinical depression: the role played by depression associated with somatic symptoms. Am J Psychiatry. 1999; 156:480-482.
37. Born L, Steiner M. The Relationship between menarche and depression in adolescence. CNS Spectrums 2001; 6(2): 126-138.
38. Allgood-Merten B, Lewinsohn PM, Hops H. Sex differences and adolescent depression. J Abnorm Psychol. 1990; 99:55-63.
39. Olsson G, von Knorring A-L. Beck’s Depression Inventory as a screening instrument for adolescent depression in Sweden: gender differences. Acta Psychiatr Scand. 1997; 95:277-282.
40. Chartier GM, Ranieri DJ. Adolescent depression: Concepts, treatments, prevention. In P. Karoly & J. J. Steffen (Eds.), Adolescent behavior disorders: Foundations and contemporary concerns. ADVANCES IN CHILD BEHAVIORAL ANALYSIS AND THERAPY, 3. Lexington, MA: Lexington Books, 1984; 153-193.
41. Weiner IB. Psychopathology in adolescence. In J. Adelson (Ed.), HANDBOOK OF ADOLESCENT PSYCHOLOGY. New York: John Wiley & Sons. 1980; 447-471.
42. Friedrich W, Reams R, Jacobs J. Depression and suicidal ideation in early adolescents. Journal of youth and adolescence. 1982 11, 403-407.