Asian Journal of Psychiatry 57 (2021) 102581

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Asian Journal of Psychiatry

journal homepage: www.elsevier.com/locate/ajp

Review article

A meta-analysis on the prevalence of depression in perimenopausal and

postmenopausal women in India
Vikas Yadav a, Akanksha Jain a, Deepti Dabar b, *, Akhil Dhanesh Goel c, Akanksha Sood d,
Ankur Joshi b, Sanjay S. Agarwal a, Sunil Nandeshwar e
a
Department of Community Medicine, Atal Bihari Vajpayee Government Medical College, Vidisha, India
b
Department of Community and Family Medicine, AIIMS, Bhopal, India
c
Department of Community Medicine and Family Medicine, AIIMS, Jodhpur, India
d
Department of Obstetrics and Gynaecology, St. Mary’s Hospital, Oxford Road, Manchester, UK
e
Atal Bihari Vajpayee Government Medical College, Vidisha, India

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: The mental health of perimenopausal and postmenopausal women is a relatively understudied area.
Prevalence This review formally explores the prevalence of depression in perimenopausal and postmenopausal women in
India India.
Meta-analysis
Methods: Databases like PubMed, Embase, Cochrane library, Web of Science and Scopus were systematically
Depression
Menopause
searched for cross-sectional or cohort studies, providing prevalence of depression in Indian perimenopausal and
Women postmenopausal women. Systematic study selection and data extraction procedures were followed. Quality
Climacteric assessment of individual study was done using AXIS tool. For pooling of effect sizes, the random effects model
was used. Funnel plot and Egger’s test were used to ascertain publication bias. Subgroup analyses and meta-
regression analysis were used to explore heterogeneity in the summary estimates.
Results: After a thorough search, ten studies were found to be eligible and included in this review. Pooled esti­
mate for prevalence of depression (random effects model) in perimenopausal and postmenopausal women in
India is 42.47 % (95 % CI: 28.73–57.49, I2 = 97.7 %). On visual inspection of the funnel plot and interpreting
egger’s test (bias: 3.49, SE bias: 3.68, p = 0.37), there was absence of publication bias.
Conclusion: We documented 42.47 % pooled prevalence of depression in perimenopausal and postmenopausal
women in India.

1. Introduction (Soares, 2019). Common physical symptoms during the menopausal

Menopause is a crucial transition in women’s lives, in which several
biological and psychological changes take place (Freeman, 2015).
Menopause is defined post hoc as a complete cessation of menstrual
bleeding for at least one year. Perimenopause is defined as the time from
the start of irregular periods until one year after menopause
(Ahuja, 2016). Mean menopause age in India is 45.5 (± 5.5 SD) years
(Ahuja, 2016). Perimenopausal period ranges from 2 years to 8 years
with a mean duration of 5 years (Treloar, 1981; Santoro, 2016).
Women often display clinical signs and symptoms corresponding to
hormonal, psychological and physical changes in their body
transition include hot flushes, night sweating, breast tenderness, vaginal
dryness, migraine and insomnia. Anxiety, stress, mood swing and
depression are common psychological symptoms (Di et al., 2019;
Freeman, 2015; Soares, 2019).
Depression is often described as the loss of interest in routine life, loss
of pleasure in previously pleasurable activities and depressed mood for
more than two weeks (Bromberger and Epperson, 2018; Di et al., 2019).
Lifetime estimated prevalence of major depression is 17 %, and its
incidence is nearly two times in females as compared to males
(Kessler et al., 1994). Depression in the female is known to be associated
with reproductive events, which is also called reproductive-related

* Correspondence author at: Department of Community and Family Medicine, AIIMS, Bhopal, India.
E-mail addresses: drvikasyadav@gmail.com (V. Yadav), dr.akanksha3186@gmail.com (A. Jain), deepti.dabar@gmail.com (D. Dabar), doc.akhilgoel.aiims@gmail.
com (A.D. Goel), drakankshasood@gmail.com (A. Sood), ankur.cfm@aiimsbhopal.edu.in (A. Joshi), agarwalsanjay8@rediffmail.com (S.S. Agarwal),
drsunilnandeshwar@gmail.com (S. Nandeshwar).

https://doi.org/10.1016/j.ajp.2021.102581
Received 21 November 2020; Received in revised form 20 January 2021; Accepted 24 January 2021
Available online 5 February 2021
1876-2018/© 2021 Elsevier B.V. All rights reserved.
V. Yadav et al.
depressive episodes. The premenstrual dysphoric disorder (PMDD) is
linked with the menstrual cycle, and incidence of depression is more in
the postpartum period and perimenopausal period (Soares, 2019). This
occurs due to changes in the hormonal environment in the luteal phase
of the cycles, in the postpartum period and the menopause transition
(Soares, 2019).
In the perimenopausal period, women with no history of depression
may experience depressed mood two to four times as compared to pre­
menopausal women, and this risk is even higher in women with a history
of depression (Bromberger and Kravitz, 2011; Freeman, 2010). This
debilitating depression in perimenopausal period could impair func­
tional outcomes and can also deteriorate their quality of life
(Ho et al., 2017; Park and Kim, 2018).
Various prevalence studies conducted worldwide reported that the
prevalence of depression in perimenopausal and postmenopausal
women is exceptionally high (Afshari et al., 2015; Chedraui et al., 2009;
Gonçalves et al., 2013; Onya and Otorkpa, 2018; Yen et al., 2009).
Psychiatric health of menopausal women has not been add
ressed separately in the National Mental Health Prog
ramme (of India) and India’s National Mental Health Policy (2014)
(Gupta and Sagar, 2018; Wig and Murthy, 2015).
It has also been documented in previous studies that the prevalence of
depression in this group is enormously influenced by economic and socio-
cultural circumstances; hence prevalence estimates of other countries are
not an accurate proxy for India (Compton et al., 2006; Kleinman, 2004).
Though national level survey to assess the burden of mental illnesses
among various age categories was conducted in India in 2015− 16; still, it
did not provide the prevalence of psychiatric illnesses in perimenopausal
or postmenopausal women (Gautham et al., 2020). For that reason, there
is still a scarcity of nationally representative data for depression preva­
lence in this group of women. Therefore, we planned to conduct this
systematic review and meta-analysis with the aim to explore the preva­
lence of depression in perimenopausal and postmenopausal women in
India. The current study is an attempt to investigate the prevalence and
hence highlighting the case of depression in perimenopausal and post­
menopausal women. This calls for informed policy decisions towards
better management of the situation.
2. Methods
This review is reported according to the ‘Preferred Reporting Items for
Systematic Reviews and Meta-Analyses’ (PRISMA) statement
(Liberati et al., 2009), and this review is registered with the PROSPERO
database (ID: CRD42020191934).
2.1. Eligibility criteria
We included all the studies reporting the prevalence of depression in
perimenopausal and postmenopausal women in India.
2.1.1. Inclusion criteria
1) Studies Type: Cross-sectional or Cohort studies
2) Studies conducted in perimenopausal and postmenopausal women
3) Studies reported the prevalence of depression/ Depressive symp­
toms/ Depressive Disorders
4) Studies conducted in Indian population
5) Studies in which depression assessed using any one of the depression
screening (or diagnostic) scale
2.1.2. Exclusion criteria
1) Studies conducted in a specific sub-set (i.e. studies conducted in
women suffering from a particular disease etc.)
2) Studies,not providing relevant data for the prevalence of depression
3) Studies reporting sub-category of depression
2
Asian Journal of Psychiatry 57 (2021) 102581
4) Case reports and reviews
5) Studies, not using any standard scale for assessing depression
6) Studies reporting the prevalence of subjective or self-perceived
depression
2.2. Information sources
We searched for relevant articles using online databases like
PubMed, Embase, Cochrane library, Web of Science and Scopus. Search
queries were done on 10th of June 2020, and articles published up to
this date were included. While conducting these searches, any date or
language restrictions were not applied. Bibliographies of selected arti­
cles were also explored to find additional relevant studies. The themes of
search items were menopausal status, geographic area (i.e. India),
depression, women, and prevalence. The detailed search strategy used
on PubMed is provided in Table 1.
2.3. Study selection
All search results were uploaded to Rayyan QCRI
(https://rayyan.qcri.org), an online citation screening tool
(Ouzzani et al., 2016). A reviewer (VY) identified and removed
duplicate citations and ‘switched on’ the ‘blind mode’ to ensure an
independent selection of relevant studies. In the first stage, two re­
viewers (ADG and DD) independently screened titles and abstracts of
all the included studies in search results considering eligibility criteria.
In the second stage, full-text copies of all selected studies were ob­
tained, and exclusions of more articles were done based on the eligi­
bility criteria. Reasons for exclusions were also documented for each
excluded article explored as full text. In the third stage, the third
reviewer (VY) identified discrepancies among selected articles by
‘switching off’the ‘blind mode’. Differences were discussed and
resolved by building consensus among reviewers (ADG, DD and VY).
Finally, we arrived at the list of studies fulfilling all the inclusion and
exclusion criteria.
2.4. Data extraction
From all the selected eligible studies, two reviewers (ADG and DD)
independently extracted relevant information. Data were extracted
regarding author, year of publication, age of participants, the screening/
diagnostic instrument used, population (menopausal or perimenopausal
women or both), residence (district, state), area (urban or rural or both),
setting (hospital or community based), type of sampling and prevalence
data (total participants included, number of participants found
depressed). Inconsistencies were again resolved by building consensus
among reviewers (ADG, DD and VY).
2.5. Quality assessment of the studies
To ascertain the quality of the included studies for their mathemat­
ical rigour, ‘Critical appraisal tool to assess the quality of cross-sectional
Table 1
Search strategy used in PubMed.
Themes Keywords
1 Menopausal menopausal OR postmenopaus* OR post-menopaus* OR
status premenopaus* OR pre-menopaus* OR perimenopaus* OR
peri-menopaus* OR “midlife” OR climacteric
2 Geographic area India*
3 Depression psychiatric OR depressi* OR mental
4 Women “women” or “female”
5 Prevalence prevalence OR epidemiology
Note: • We used the Boolean operator ‘AND’ to combine all themes
in search.
• Any date or language restrictions were not applied.
V. Yadav et al.
studies’ (AXIS tool) was used (Downes et al., 2016). This tool consists of
20 questions, which needs to be responded to as ‘yes’, ‘no’ or ‘don’t
know’. Two reviewers (ADG and DD) critically appraised each study
independently using this critical appraisal tool. Discrepancies found
during the critical appraisal were resolved by the discussion with the
third reviewer (VY). Studies having thirteen or more score (out of 20)
were considered as good quality studies.
2.6. Data synthesis and analyses
The effect sizes for current meta-analysis are prevalence estimates of
depression in perimenopausal and postmenopausal women of India,
which were calculated based on prevalence estimates obtained from
each selected research article. After that, the pooled estimate of
depression prevalence was calculated.
Generalised Linear Mixed Models (GLMMs) Logit transformation
methods for transforming single proportion were used to calculate effect
sizes for each study, as these methods are preferred in calculating effect
size in such a situation (Schwarzer et al., 2019).
I squared (I2) statistic and Cochran’s Q test were used to examine
heterogeneity between studies. Due to considerable heterogeneity (I2 =
97.7 %, Cochran’s Q = 174.24, df = 9, p-value < 0.0001) between the
studies, random effects model was used in analysis
(Higgins and Thompson, 2002). Tau squared was calculated using
Restricted Maximum-Likelihood Estimator (REML) method.
Clopper-Pearson method was used to calculate confidence intervals of
effect sizes of individual studies. All effect sizes and pooled estimates are
reported as proportions with 95 % confidence intervals. Visual inspection
of funnel plots and egger’s test provided evidence for publication bias if
any (Egger et al., 1997). Data extraction was done in Microsoft excel
2019 software. Meta and Metafor packages of R software were used to
conduct all the statistical analyses (Schwarzer, 2007; Viechtbauer, 2010).
Subgroup analyses and meta-regression analysis were performed to
Fig. 1. PRISMA Flowchart of study selection.
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Asian Journal of Psychiatry 57 (2021) 102581
investigate the source of heterogeneity. Subgroup analyses were con­
ducted for screening instrument (HAM-D or other), population (meno­
pausal or perimenopausal women or both), Zonal council administrative
division of India (Northern or Southern or Central or Western or
Eastern), (Government of India, 2014) year of publication (before the
year 2016 or year 2016 and after), residence (urban or rural or both),
setting (hospital or community) and sampling method (random or
non-random). Sensitivity analysis was done to exclude studies with
lower quality (AXIS score of less than 13).
3. Results
From all the databases, a total of 332 articles were identified. After
removing duplicates, exclusions were made by reviewing titles and ab­
stracts. Full texts of 96 articles were screened. Total of 10 cross-sectional
studies fulfilled eligibility criteria and were thus eligible for inclusion in
this systematic review and meta-analysis (Aaron et al., 2002; Ahlawat
et al., 2019; Bansal et al., 2015; Dutta et al., 2018; Jagtap et al., 2016;
Nayak et al., 2019; Ps et al., 2017; Santwani et al., 2010; Singh and
Pradhan, 2014; Tamaria et al., 2013). We did not find any eligible cohort
study for our review. Fig. 1 depicts the study selection process.
Most (5 studies) of the studies were published in the year 2016 and
later. Among the included studies, the most frequently used depression
screening instrument was the Hamilton Depression Rating Scale (HAM-
D, 4 studies). Remaining five studies used Screening for Depression
Questionnaire-9 (SDQ-9, 1 study), Zung Self-Rating Depression Scale
(ZSDS, 1 study), Mini International Neuropsychiatric Interview (MINI, 1
study), Inventory of Depressive Symptomatology Self Report (IDS-SR, 1
study), Patient Health Questionnaire (PHQ-9, 1 study) and Center for
Epidemiologic Studies Depression Scale (CES-D, 1 study) for screening
depression. Total 7 studies conducted over postmenopausal women, 1
was conducted over perimenopausal women and 2 studies covered both.
An equal number (4 studies each) of studies were from Northern and
V. Yadav et al. Asian Journal of Psychiatry 57 (2021) 102581

Southern India, and only two studies were conducted in Western India.
We did not find any study conducted in Eastern or Central India. Most (7
studies) of the studies were conducted in the community-based setting,
and rest (3 studies) were conducted in the hospital-based setting. Most of
the studies were from rural areas (5 studies), followed by urban (4
studies) and mixed (1 study) areas. Random sampling was the most
commonly employed sampling procedure (8 studies) and 2 studies did
not report sampling methods. Total 8 studies were found to be of high
quality (AXIS score 13 or more), and 2 studies were of low quality (score
less than 13) on methodological quality assessment (Table 2).
3.1. The pooled prevalence of depression
Pooled estimate for depression (random effects model) in perimen­
opausal and postmenopausal women in India was 42.47 % (95 % CI:
28.73–57.49, Tou2: 0.9166, I2 = 97.7 %, Cochran’s Q = 174.24, df = 9,
p-value < 0.0001) (Fig. 2).
3.2. Subgroup analyses
Studies used HAM-D (4 studies, 43.58 %; 95 % CI: 24.25− 65.08) for
screening depression showed higher estimates of depression prevalence
as compared to studies using other screening (6 studies, 41.67; 95 % CI:
23.99− 61.79) scales but the difference was not statistically significant
(p = 0.90).
The pooled prevalence of depression in postmenopausal women (7
studies, 37.83 %; 95 % CI: 25.83− 51.53) is lower as compared peri­
menopausal women or mixed population (3 studies, 53.17 %; 95 % CI:
21.91− 82.13) but the difference is not statisticallysignificant (p = 0.42).
India is administratively divided into five zonal councils, i.e.
Northern, Southern, Central, Western and Eastern. In our review, we did
not find any study conducted in Eastern or Central zonal council. Pooled
prevalence was highest in Western zonal council (2 studies, 56.28 %; 95
% CI: 22.49− 85.10) followed by Northern (4 studies, 53.17 %; 95 % CI:
29.70− 75.33) and Southern (4 studies, 27.35 %; 95 % CI: 22.80–32.43)
zonal council and difference was significant (p = 0.03).
Studies published before the year 2016had estimated pooled preva­
lence of 56.35 % (5 studies, 95 % CI: 32.29− 77.75), which was higher
than the studies published in the year 2016 or later (5 studies, 30.57 %;
95 % CI: 24.62− 37.25) and the difference was significant (p = 0.04).
Studies conducted in urban (4 studies, 46.85 %; 95 % CI:
27.64− 67.03) areas exhibited higher pooled prevalence of depression as
compared to studies conducted in rural (5 studies, 41.28 %;
20.90− 65.16) or both, rural and urban (1 study, 31.48 %; 95 % CI:
23.43− 40.81) areas (difference non-significant, p = 0.1286).
Studies conducted in hospital setting (3 studies, 51.87 %; 95 % CI:
28.61− 74.34) recorded higher pooled prevalence as compared to the
studies conducted in community setting (7 studies, 38.60 %; 95 % CI:
23.43− 56.37) but this difference was statistically non-significant (p =
0.39).
Studies carried out with random sampling methods (8 studies, 37.64
%; 95 % CI: 24.27–53.21) were documented lower prevalence as
compared to studies without reporting of sampling methods (2 studies,
62.37 %; 95 % CI: 35.65− 83.22) but the difference was statistically non-
significant with a p-value of 0.12.

Table 2
Characteristics of the studies included in Meta-analysis.
S. Study Location Area Study Setting Diagnostic Population type Sampling Age Sample No. Quality
No. design scale used size Depression score

1 Aaron Vellore, Tamil rural cross- community SDQ-9 postmenopausal Multistage 40− 49 100 29 15
et al. Nadu, sectional based sampling years
(2002) Southern
2 Ahlawat Delhi, Delhi, urban cross- community HAM-D postmenopausal Systematic 41− 60 580 241 (mild 15
et al. Northern sectional based random years = 222,
(2019) sampling moderate
= 19)
3 Bansal Ludhiana, rural cross- community ZSDS perimenopausal PPS 40− 60 136 118 (mild 14
et al. Punjab, sectional based and years = 39,
(2015) Northern postmenopausal moderate
= 67,
severe =
12)
4 Dutta Chennai, urban cross- community HAM-D postmenopausal All eligible 41− 60 171 42 (mild = 13
et al. Tamil Nadu, sectional based women of years 36,
(2018) Southern area moderate
included = 6)
5 Jagtap Loni, urban cross- hospital MINI perimenopausal Consecutive 45− 55 108 34 11
et al. Maharashtra, and sectional based eligible years
(2016) Western rural women in
OPD
6 Nayak Udupi, rural cross- community IDS-SR postmenopausal Multistage 51.68 290 65 (mild = 16
et al. Karnataka, sectional based sampling ± 4.2 60,
(2019) Southern years moderate
= 5)
7 PS et al. Alappuzha, rural cross- community PHQ9 perimenopausal Cluster 40-60 477 159 16
(2017) Kerala, sectional based and sampling years
Southern postmenopausal
8 Santwani Jamnagar, urban cross- hospital HAM-D postmenopausal Not 40− 50 48 38 10
et al. Gujarat, sectional based Reported years
(2010) Western
9 Singh Delhi, Delhi, rural cross- community HAM-D postmenopausal Multistage 40− 54 252 81 (mild = 13
et al. Northern sectional based sampling years 78,
(2014) moderate
= 3)
10 Tamaria Delhi, Delhi, urban cross- hospital CES-D postmenopausal Not 46.8 ± 200 89 13
et al. Northern sectional based Reported 2.9
(2013) years

4
V. Yadav et al. Asian Journal of Psychiatry 57 (2021) 102581

Fig. 2. Forest plot of the prevalence of depression in perimenopausal and postmenopausal women in India.

3.3. Quality assessment
AXIS Quality score of included studies ranges from 10 to 16 with a
median of 13.5. There was a total of 8 high quality studies and two low
quality studies included in this review.
Quality scores for each study are provided in Table 2.
3.4. Sensitivity analysis
On sensitivity analysis, omitting lower quality studies (AXIS score
less than 13) pooled prevalence declined to 39.29 % with 95 % CI of
25.64–54.86 (Tou2: 0.7996, I2 = 97.8 %, Cochran’s Q = 144.99, df = 10,
p-value < 0.0001), which is lower than the overall pooled prevalence
(42.47 %) (Table 3).
3.5. Meta-regression analysis
On meta-regression analysis, we found that meta-analysis results are
not associated with quality of studies (B = − 0.19, z = − 1.25, p-value =
0.21).
3.6. Influential analysis
On influential analysis, pooled results of the meta-analysis are not
significantly affected by data of any single study.
3.7. Publication bias
The results of egger’s test (bias: 3.49, SE bias: 3.68, p = 0.37) did not
provide any evidence of publication bias. On visual inspection of the
funnel plot, it looks reasonably symmetrical, which also supports the
findings of egger’s test. (Fig. 3)
4. Discussion
With this meta-analysis, we have estimated pooled prevalence of
perimenopausal and postmenopausal depression from 10 studies. We
found that pooled estimate for depression (random effects model) in
perimenopausal and postmenopausal women in India was 42.47 % (95
% CI: 28.73–57.49). Various small and large studies conducted in other
parts of the world also documented a remarkably high prevalence of
depression in this group (Afshari et al., 2015; Chedraui et al., 2009;
Gonçalves et al., 2013; Onya and Otorkpa, 2018; Yen et al., 2009).
Zeng et al. (2019) conducted a meta-analysis of studies of Chinese
population documented 36.3 % prevalence of depression in menopausal
women (Zeng et al., 2019). On sensitivity analysis, after omitting lower
quality studies, we documented the estimated pooled prevalence of
39.29 %, which is very similar to results found by Zeng et al. (2019).
Risk factors for depression in these women can be divided into three
major categories. First, biological factors, i.e. fatigue, sleep disturbances,
vasomotor symptoms, obesity, and chronic medical condition (Brom­
berger et al., 2007; Dennerstein et al., 2000, 1999; Woods et al., 2009).
Second, behaviour and social factors, i.e., physical inactivity, relationship
issues, financial issues, unemployment, retirement, social isolation, and
poor social support (Bromberger et al., 2007; Dennerstein et al., 1999;
Freeman et al., 2004; Sternfeld et al., 2014; Woods et al., 2009, 2008).
Third, psychological factors, i.e. previous history of depression or anxiety
and stressful life event (Bromberger et al., 2009; Dennerstein et al., 2000;
Woods et al., 2009). The data also suggest that depressed mood in the
menopausal transition is multifactorial and not merely due to menopausal

Table 3
Subgroup analysis of prevalence of depression in menopausal women in India.
Subgroup Categories (no. of studies) Prevalence in % 95 % CI in % I2 in % Between group Q (p value)

Instrument HAM-D (4) 43.58 24.25− 65.08 97.1 0.02 (0.90)

Other (6) 41.67 23.99− 61.79 97.6
Population type Postmenopausal (7) 37.83 25.83− 51.53 96.0 0.66 (0.42)
Perimenopausal or mixed (3) 53.17 21.91− 82.13 97.9
Zone Northern (4) 53.17 29.70− 75.33 98.2 6.81 (0.03)
Southern (4) 27.36 22.80− 32.44 62.4
Western (2) 56.28 22.49− 85.10 92.7
Year of publication Before 2016 (5) 56.35 32.29− 77.75 97.1 4.11 (0.04)
2016 and later (5) 30.57 24.62− 37.25 85.7
Area Rural (5) 41.28 20.90− 65.16 98.2 2.21 (0.33)
Urban (4) 46.85 27.64− 67.03 96.7
Mixed (1) 31.48 23.43− 40.81 –
Setting Community (7) 38.60 23.43− 56.37 98.1 0.74 (0.39)
Hospital (3) 51.87 28.61− 74.34 93.8
Sampling Random (8) 37.64 24.27− 53.20 97.6 2.45 (0.12)
Not Reported (2) 62.37 35.65− 83.22 88.3

5
V. Yadav et al.
Fig. 3. Funnel plot with transformed prevalence on the x-axis and standard error of transformed proportions on the y-axis.
status alone (Freeman, 2015). The association of menopause and depres­
sion is possibly due to the changes in the level of reproductive hormone
alter neuroregulatory system responsible for mood and behaviour
(Rubinow et al., 1998; Schmidt and Rubinow, 2009); still, the actual
reason for depression in menopausal transition is not yet known
(Freeman, 2015; Soares, 2019).
In the current meta-analysis, we found that studies used HAM-D for
screening depression are reporting slightly higher estimates of depres­
sion prevalence as compared to studies using other screening, but the
difference was not significant. Various scales for screening depression
has been developed and validated to use in different settings and pop­
ulation. Sensitivity and specificity of depression screening scales may
vary; hence their results may also come out different from each other
(Behera et al., 2017).
In the current meta-analysis, we have documented that pooled preva­
lence of depression in postmenopausal women is lesser as studies comprise
of perimenopausal or both as participants. These results are in accordance
with previous studies in which the prevalence of depression is more in
perimenopausal women than postmenopausal women
(Dennerstein et al., 2004; Tangen and Mykletun, 2008). In perimenopausal
women, due to the hormonal transition, vasomotor symptom, negative
attitude towards menopause, ageing and poor health due to other diseases,
depression may precipitate more often (Freeman, 2015).
In our review, we have found that pooled prevalence was higher in
Western and Northern zonal councils, and it is comparatively low in
Southern zonal council. In previous studies, it has been reported that lower
socioeconomic status and lack of education increases the chances of having
depression (Rai et al., 2013). The lower prevalence of depression in the
Southern zone may be due to higher education level and less of poverty in
these states (Chandramouli, 2011; Ministry of Statistics and Programme
Implementation, 2011).
In the current research, we reported that study published before the
year 2016 were having a higher prevalence than the studies published in
the year 2016 or later. India framed the National Mental Health Policy of
India in 2014 (Wig and Murthy, 2015). Since then, several initiatives
have been taken to incorporate mental health in routine health care, and
this might be the reason for improved indicators found in studies pub­
lished in 2016 or later years in the current review (Sharma, 2014).
In the current review, studies conducted in urban area were exhib­
iting higher pooled prevalence of depression as compared to studies
conducted in rural or both, rural and urban areas. National Mental
Health Survey of India (2015− 16) also found that the prevalence of
almost all mental disorders, including depression in the adult popula­
tion, were high in the urban areas as compared to rural areas
6
Asian Journal of Psychiatry 57 (2021) 102581
(Gautham et al., 2020). Modern lifestyle, competitive work environ­
ments, poverty, nuclear families, migration and poor living conditions in
slums of urban areas could be an explanation for the higher prevalence
of depression in urban areas (Gautham et al., 2020).
In our meta-analysis, studies, carried out with random sampling
methods, documented lower prevalence as compared to studies not
reporting sampling methods. Studies with random sampling methods
may be more representative of the population and have lesser selection
bias. Those studies, which have not reported sampling methods, might
have used convenient sampling methods and overestimated the
prevalence.
In this review, studies conducted in the hospital setting, recorded
higher pooled prevalence as compared to studies conducted in the
community setting, but these differences were statistically non-
significant. Most (2 out of 3) of the hospital-based studies in the cur­
rent review have not reported sampling methods, and selection bias is a
probable explanation for higher prevalence. Participants from the hos­
pital setting are at higher risk of developing depression due to illness, for
which they have visited the hospital, so getting a higher prevalence of
depression in them is likely.
5. Conclusion
This meta-analysis reports that 42.47 % (95 % CI: 28.73–57.49) of
perimenopausal and postmenopausal women have some form of depres­
sion. There is no separate mention of mental health in menopausal women
in India’s National Mental Health Programme and the National Mental
Health Policy (2014) (Gupta and Sagar, 2018; Wig and Murthy, 2015).
Considering this high burden of depression in perimenopausal and post­
menopausal women, India should assign a higher priority to menopausal
mental health and include the screening of depression for this group in
routine care.
6. Limitation
We found only ten suitable studies from a country of 1.3 billion
population, so publication bias is likely. Many of the included studies
have not provided a detailed explanation regarding employed methods;
therefore, selection bias is also possible. Depression prevalence provided
by screening tools cannot be considered as the prevalence of clinical
depression. Nevertheless, participants found positive on screening
scales, can be referred to a psychiatrist or monitored for deterioration of
the condition.
V. Yadav et al. Asian Journal of Psychiatry 57 (2021) 102581

Funding Gonçalves, B., Fagulha, T., Ferreira, A., 2013. A population-based assessment of the
relationship between menopausal and depressive symptoms in portuguese women.
Health Care Women Int. 34, 86–100.
Authors have not received any funding for conducting this system­ Government of India, 2014. The States Reorganisation Act, 1956. Government of India,
atic review and meta-analysis. New Delhi. http://interstatecouncil.nic.in/iscs/wp-content/uploads/2016/08/states
_reorganisation_act.pdf.
Gupta, S., Sagar, R., 2018. National mental health programme-optimism and caution: a
narrative review. Indian J. Psychol. Med. 40, 509–516.
Declaration of Competing Interest Higgins, J.P., Thompson, S.G., 2002. Quantifying heterogeneity in a meta-analysis. Stat.
Med. 21, 1539–1558.
The authors declare that they have no conflict of interest. Ho, S.C., Liang, Z., Yu, R.H., Sham, A., 2017. Association of life events and depressive
symptoms among early postmenopausal Chinese women in Hong Kong. Menopause
(New York, N.Y.) 24, 180–186.
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