Review Article

Risk and protective factors associated with adolescent

depression in Singapore: a systematic review
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Wei Sheng Goh1, MBBS, Jun Hao Norman Tan1, MBBS, Yang Luo1, MBBS, Sok Hui Ng1, MBBS, Mohamed Sufyan Bin Mohamed Sulaiman2, BSc Psych,
MSc Health Psych, John Chee Meng Wong3, MBBS, MMed (Psych), Victor Weng Keong Loh2, MBBS, MMed (Fam Med)
1
Yong Loo Lin School of Medicine, National University of Singapore, 2Division of Family Medicine, Yong Loo Lin School of Medicine, National University of Singapore,
3
Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
YQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 03/14/2024

Abstract
Introduction: Adolescent depression is prevalent, and teen suicide rates are on the rise locally. A systemic review to understand associated
risk and protective factors is important to strengthen measures for the prevention and early detection of adolescent depression and suicide in
Singapore. This systematic review aims to identify the factors associated with adolescent depression in Singapore.
Methods: A systematic search on the following databases was performed on 21 May 2020: PubMed, EMBASE and PsycINFO. Full texts
were reviewed for eligibility, and the included studies were appraised for quality using the Newcastle Ottawa Scale. Narrative synthesis of
the finalised articles was performed through thematic analysis.
Results: In total, eight studies were included in this review. The four factors associated with adolescent depression identified were: (1) sociodemographic
factors (gender, ethnicity); (2) psychological factors, including childhood maltreatment exposure and psychological constructs (hope, optimism);
(3) coexisting chronic medical conditions (asthma); and (4) lifestyle factors (sleep inadequacy, excessive internet use and pathological gaming).
Conclusion: The identified factors were largely similar to those reported in the global literature, except for sleep inadequacy along with
conspicuously absent factors such as academic stress and strict parenting, which should prompt further research in these areas. Further research
should focus on current and prospective interventions to improve mental health literacy, targeting sleep duration, internet use and gaming, and
mitigating the risk of depression in patients with chronic disease in the primary care and community setting.

Keywords: Adolescent health, depression, mental health, risk factors, Singapore

INTRODUCTION smoking and substance abuse, and a higher prevalence of

Adolescence (10–19 years, World Health Organization [WHO])
is a period of rapid physical, cognitive and social transformation
that leads to acquisition of the roles and responsibilities of
adulthood. While adolescents are mostly physically healthy,
this period is marked by experimentation and risk taking,[2]
and significant morbidity in terms of mental illness. Half of
all mental health problems have an onset before the age of 14,
and three-quarters before the age of 25.[3]
Depression is a leading cause of illness and disability globally.
With an estimated 1‑year prevalence of 4%–5% of depression
among youth in the mid‑ to late-adolescent age group,[4,5] it
poses a threat to adolescent well‑being. Adolescent depression
is associated with health‑compromising behaviours, such as
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and poorer outcomes for chronic medical conditions such as
[1]
obesity[6] and insulin‑dependent diabetes mellitus.[7] It also
heightens the risk of suicide,[8] the third leading cause of death
among 15–19‑year‑olds worldwide,[9] and is an impediment
to socio‑educational attainment.[10,11] The United Nations
Youth Strategy (UN2030) has prioritised the provision of
youth‑friendly mental health services to address the adverse
Correspondence: Dr. Wei Sheng Goh,
Yong Loo Lin School of Medicine, National University of Singapore,
10 Medical Drive, 117597, Singapore.
E‑mail: weisheng.goh@mohh.com.sg
Received: 16 May 2021 Accepted: 17 Oct 2021 Published: 26 Apr 2023
This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
is given and the new creations are licensed under the identical terms.
For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com

DOI: How to cite this article: Goh WS, Tan JHN, Luo Y, Ng SH, Sulaiman MSBM,
10.4103/singaporemedj.SMJ-2021-192 Wong JCM, et al. Risk and protective factors associated with adolescent
depression in Singapore: a systematic review. Singapore Med J 0;0:0.

© 2023 Singapore Medical Journal | Published by Wolters Kluwer - Medknow 1

 Goh, et al.: Factors for adolescent depression in Singapore

trajectories of patients and their families that may result from
untreated adolescent depression.[10,11]
Locally, the Singapore Mental Health Survey (SMHS 2016)[12]
found that the lifetime prevalence of depression in adults
aged 18 years and above increased from 5.8% in 2010 to
6.3% in 2016. Mental disorders contribute to 20%–25%
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‘singapore’ AND ‘factor OR associat* OR relationship* OR
Predict OR Prevalence OR Course OR prognos* OR cause OR
etiolog* OR aetiolog*’. In order to ensure sufficient data, the
search strategy did not limit studies by study design.
Selection criteria
All reports that examined the risk factors for depression in

of disability‑adjusted life years (DALYs), 20%–25% of
years of life lost (YLL) and 25%–30% of years lived with
disability (YLD). In Singapore, anxiety and depressive
disorders are the leading cause of disease burden among
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the adolescent population were eligible for inclusion. We
took adolescence to refer to individuals aged between 10 and
19 years according to the WHO definition.[1] We considered
articles for review if they satisfied the following inclusion

15–34‑year‑olds and rank fifth in the 0–14 years age category. criteria: peer‑reviewed scientific reports of original research;
In 2019, almost 2,000 youth (aged 16–30 years) engaged CHAT English language articles; study population with a mean
(Community Health Assessment Team), a community‑based age of 10–19 years; study population resided in Singapore;
youth mental health outreach, an increase of 36 times from and studies that reported associations with depression as
its inception in 2009.[13,14] In Singapore, suicide remains the an outcome measure. The exclusion criteria were informal
leading cause of death for persons aged 10–29 years. Among publications (such as commentaries, letters to the editor,
adolescents aged 10–19 years, a high of 19 suicides among editorials, meeting abstracts), review papers, non‑English
teen males were documented in 2018. Among females, ten papers, studies with lack of access to full texts and studies
teen suicides were documented in 2019, a more than three‑fold that did not focus on depression as an outcome. The selection
increase from 2018.[15] Hence, at the 2019 Youth Conversations of documents for eligibility was evaluated independently, first
organised by the National Youth Council, mental health was using the title and abstract and subsequently using the full text,
cited as an issue of national concern among youth. to ensure they met the inclusion and exclusion criteria.
There are many factors associated with depression. These Quality appraisal
include a strong family history of depression,[16‑18] sleep All included studies were appraised using the Newcastle
deprivation, genetic factors[19] and the presence of chronic Ottawa Scale. The scores for risk of bias are tabulated in
medical conditions. Predisposing factors include history of Table 1. The quality appraisal process was peer reviewed by
mental disorders, attempted self‑harm, disruptive behaviour, the team of authors. The studies were ranked to be of good, fair
learning problems, negative body image, heightened
sensitivity to loss and rejection, chronic adversity including
maltreatment, family discord, bullying and poverty,[20] as well Table 1. Risk of bias assessment.
as frequent clinic attendance, lack of social support and lower Study Newcastle Ottawa Quality
socioeconomic status. Stressors such as academic pressure, Assessment Scale
abuse, personal injury and loss[20‑22] act as additional risk Selection Comparability Outcome
factors. (max. 5) (max. 2) (max. 3)
Magiati et al. (2015)[30] 5 0 0
Singapore is a Southeast Asian city‑state at the crossroads
Mythily et al. (2008)[37] 2 0 2
of global trade, imbued with a sociocultural amalgamation
Peh et al. (2017)[32] 2 1 2
of Asian collectivism[23‑25] and Western individualism,[26]
Wong and Lim (2009)[33] 4 2 2
and oriented nationally towards academic and economic
Yeo et al. (2019)[35] 5 2 2
competitiveness.[27] This systematic review seeks to understand
Lu et al. (2014)[34] 2 2 2
the risk and protective factors associated with depression Lo et al. (2018)[36] 1 2 3
among adolescents growing up in multicultural Singapore. Gentile et al. (2011)[38] 3 2 2

METHODS
Design and search strategy Table 2. Quality assessment interpretation (AHRQ
The protocol for this review was designed based on the standards).
Preferred Reporting Items for Systematic reviews and Quality Newcastle Ottawa Quality Assessment Scale
Meta‑Analysis (PRISMA) statement. We conducted a systematic assessment
Selection Comparability Outcome
search on the following databases: PubMed, EMBASE and (max. 5) (max. 2) (max. 3)
PsycINFO on 21 May 2020 with adapted search terms for each Good quality 3 or 4 1 or 2 2 or 3
database [see Appendix]. The following search terms were used: Fair quality 2 1 or 2 2 or 3
‘depressi* OR MDD OR dysthymia OR dysthymic disorder’ Poor quality 0 or 1 0 or 1 0 or 1
AND ‘adolescent* OR adolescence OR teen* OR youth*’ AND AHRQ: Agency for Healthcare Research and Quality

2 Singapore Medical Journal ¦ Volume XX ¦ Issue XX ¦ Month 2023

 Goh, et al.: Factors for adolescent depression in Singapore
or poor quality based on the Agency for Healthcare Research
and Quality (AHRQ) standards [Table 2].
Data synthesis
The included papers were qualitatively and thematically
analysed to produce a narrative synthesis.[28] A preliminary
synthesis was first undertaken by one member of the research
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team, and the identified categories were subsequently
cross‑checked and discussed with another member. The
researchers met to discuss any disagreements that arose, and
any differences in opinion were resolved through consensus.
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No ethics approval was required for this review.
RESULTS
Search results
The literature search yielded 94, 116 and 18 search results
from PubMed, EMBASE and PsycINFO, respectively,
totalling 228 studies. After 59 duplicates were removed, 169
titles and abstracts were screened based on the inclusion and
exclusion criteria, after which 128 articles were excluded.
Of the remaining 41 full‑text articles, 33 additional studies
Figure 1: PRISMA flowchart shows the selection process for the current systematic review. [Adapted from: Moher D, Liberati A, Tetzlaff J, Altman D G.
Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement BMJ 2009; 339.]
Singapore Medical Journal ¦ Volume XX ¦ Issue XX ¦ Month 2023
were excluded based on the exclusion criteria, leaving eight
articles finally. With no restrictions on study design, we have
included seven cross‑sectional studies and one interventional
study. Given the diversity of risk factors, variability in study
designs and lack of common data, a meta‑analysis could not
be performed.
All eight studies were conducted in Singapore, with sample
sizes ranging from 108 to 2998 and study settings ranging
from hospital (n = 2) to school (n = 6) settings. Regarding the
depression measures used, one study did not use a validated
depression scale, two studies used similar depression scales and
one study used a depression scale validated in Singapore (Asian
Adolescent Depression Scale).[29] A summary of the search
results is presented in the PRISMA flowchart [Figure 1]. The
study characteristics and summary of the results are presented
in Table 3.
Risk of bias assessment
The risk of bias assessment scores ranged from 4 to 9 [Table 1].
Half the studies did not have a representative sample (selection
score of 2 and below) mostly because they had a target group of
3
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4
Table 3. Summary of study characteristics and results.
Study Themes according to Study Setting Sample source and Sample Depression Results
theoretical framework: social, design source of data size measure used
biological, psychological
Magiati et al. (2015)[30] Social: ethnicity Cross- School Self‑reported questionnaire 1,655 CDI Chinese had a lower CDI total, negative mood, anhedonia
Biological: gender sectional in 18 primary schools and ineffectiveness than Malays. Males scored higher for
‘interpersonal problems’ than females. Compared to the
US population from another study, Singapore children had
higher CDI, with females scoring higher in several CDI
domains
Mythily et al. (2008)[37] Psychological: excessive internet use Cross- School Self‑reported questionnaire 2,735 Not reported Participants who reported excessive internet use, defined
sectional in three secondary schools by the author as >5 h a day, were more likely to feel sad or
depressed
Peh et al. (2017)[32] Psychological: traumatic childhood Cross- Hospital Self‑reported questionnaire 108 PHQ‑8 Severity of maltreatment exposure (measured to include
sectional in an adolescent psychiatry physical, sexual and emotional abuse and physical and
outpatient clinic emotional neglect) was associated with depressive
symptoms
Wong and Lim (2009)[33] Psychological: hope and optimism Cross- School Self‑reported questionnaire 340 CES‑D Optimism scores and depression scores were negatively
sectional in a secondary school correlated. Hope scores and depression scores were
negatively correlated. Hope and optimism contributed
significantly to depression even after controlling for
optimism and hope, respectively. Hope did not account for
depression beyond what was accounted for by optimism.
Optimism, pessimism and agency were significantly
predictive of depression
Yeo et al. (2019)[35] Biological: sleep deprivation Cross- School Self‑reported questionnaire 2,313 11‑item Kutcher Shorter sleep was associated with a higher global
sectional in six local and international Adolescent depression score. Having <7 h of sleep compared to an
secondary schools Depression Scale age‑appropriate (8−10 h) amount of sleep was associated
with depressive symptoms
Lu et al. (2014)[34] Biological: asthma Cross- Hospital Self‑reported questionnaire 171 Revised Child Adolescents with poorly controlled asthma reported
sectional in one hospital Anxiety and significantly more depressive symptoms than subjects
Depression Scale with well‑controlled asthma and healthy controls. Number
Goh, et al.: Factors for adolescent depression in Singapore

of subjects who were disturbed by depressive symptoms

Lo et al. (2018)[36] Biological: sleep deprivation
Gentile et al. (2011)[38] Psychological and social:
pathological video gaming
was found to be higher among participants with asthma,
especially those with poorly controlled asthma. Increased
ACT score was associated with lower depression scores
Cohort School Self‑reported questionnaire 375 11‑item Kutcher Increase in TIB on weekdays was associated with decrease
study in all‑girls secondary Adolescent in depressive symptoms
school Depression Scale
Cohort School Self‑reported questionnaire 2,998 Asian Adolescent
Children with more pathological gaming symptoms at
study in six primary schools and Depression Scale
baseline had higher levels of depression at 2‑year follow‑up.
six secondary schools Increase in pathological gaming symptoms between
baseline and follow‑up was associated with further increase
in depression at follow‑up. Those who became pathological
gamers ended up with increased depression, and those who
stopped being pathological gamers had lower depression

Singapore Medical Journal ¦ Volume XX ¦ Issue XX ¦ Month 2023

than those who remained pathological gamers
ACT: Asthma Control Test, CDI: Children’s Depression Inventory, CES‑D: Centre of Epidemiological Studies‑Depressed Mood Scale, PHQ‑8: 8‑item Patient Health Questionnaire, TIB: time in bed
 Goh, et al.: Factors for adolescent depression in Singapore
a selected group of users rather than a random or non‑random
sample. Some papers also fared lower in the representativeness
of the sample because they did not include the response rate
of responders/non‑responders or did not justify their sample
size. Nonetheless, most of the studies controlled for factors
and had good quality of outcomes reported.
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Factors identified
The factors identified were categorised into: (1)
sociodemographic factors (gender, ethnicity); (2) psychological
factors, including childhood maltreatment exposure and
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psychological constructs (hope, optimism); (3) coexisting
chronic medical conditions (asthma); and (4) lifestyle factors
(sleep inadequacy, excessive Internet use, pathological
gaming).
Sociodemographic factors
Magiati et al.[30] found that a substantial minority (16.9%)
of primary school‑aged Singapore children (age 8–12 years)
reported depressive symptoms based on the Children’s
Depression Inventory (CDI), which was higher than
that reported by Ramli et al.[31] for Malaysian secondary
school‑aged adolescents (10.3%).
Although little clinically significant difference in CDI scores
was found between Malay, Indian and Chinese children,
Chinese children were observed to report lower scores for
depressive symptoms (negative mood, interpersonal problems
and anhedonia, and total CDI score) compared to their Malay
and Indian peers.
While some gender differentiation was noted between Indian
girls who reported more emotional symptoms than Indian
boys, the study found no clinically significant difference in
total depression scores between males and females.
Psychological factors
Peh et al.[32] who recruited adolescents (age 14–19 years) from
a psychiatric hospital reported increased depressive symptoms
among patients with more severe childhood maltreatment
exposure. The psychometric instruments in this study collected
data on physical, sexual and emotional abuse, physical
and emotional neglect, self‑harm behaviours, emotional
dysregulation and depressive symptoms. In this study, 75.9%
reported at least one episode of self‑harm, while 50.5% reported
ten or more episodes in the past 12 months. The study found
that emotional dysregulation mediated the association between
severity of maltreatment exposure and self‑harm frequency.
Wong and Lim[33] explored the discriminant validity of ‘hope’
and ‘optimism’ on depression and life satisfaction among
Singapore secondary school students. Both constructs were
oriented towards positive outcome expectancies, correlating
positively with life satisfaction and negatively with depression.
While ‘optimism’ was related more to general positive
outcomes, ‘hope’ had the element of personal self-efficacy in
goal attainment. ‘Hope’ includes the sub-elements of agency
Singapore Medical Journal ¦ Volume XX ¦ Issue XX ¦ Month 2023
thinking (the motivation to pursue one’s goals) and pathway
thinking (the planning of a pathway towards goals attainment).
Further correlational analysis found that agency thinking
correlated negatively with depression, while pathway thinking
did not. Interestingly, the study noted gender differences in that
males tended to score higher in the ‘hope’ domain, which was
protective for depression symptoms.
Chronic medical conditions
In a cross‑sectional study, Lu et al.[34] recruited adolescent
patients (age 12–19 years) with asthma from a hospital
and then compared the rates of depression with age‑ and
gender‑ matched non‑asthma control individuals from the
same neighbourhood. They found that adolescents with
poorly controlled asthma had higher scores of depression
compared to healthy controls and patients whose asthma was
well controlled.
Lifestyle factors
Two studies reported the effect of sleep deprivation on
depressive symptoms. Not achieving age‑appropriate sleep
duration (8–10 h) on school nights was associated with
significantly increased odds for depressive symptoms (sadness,
irritability, worthlessness, low motivation, thoughts of
self‑harm) as well as poorer self‑rated health and increased
odds of being overweight.[35,36] In an interventional study
investigating the effects of delaying school start time by
45 min, a sustained increase of time in bed (TIB) and total sleep
time (TST) was documented at 9 months. This was associated
with improved alertness, reduction in depressive symptoms and
improvement in depression scores (from baseline to 9 months
change: −1.22 ± 0.48, P < 0.01).[35,36]
Two studies reported associations between excessive use of
the internet and related media and depressive symptoms in
adolescents. One cross‑sectional study reported that 17.1%
of adolescents used the internet excessively (defined as more
than 5 h of internet use a day), and this was significantly
associated with lack of home rules regarding internet use, a
lower likelihood of having a confidant, feelings of sadness
and depression and perceived poorer grades in school.[37]
Gentile et al.[38] conducted a prospective cohort study in a
population of secondary school children over 2 years to research
the association of pathological gaming with depression in
adolescents. The study found the prevalence of pathological
gaming to be around 9%. Predictor variables of pathological
gaming included impulsiveness, lower social competence
and poorer emotional regulation skills. In turn, severity of
pathological gaming was associated with depression, anxiety,
social phobia and poorer grades. These improved when the
individual stopped being a pathological gamer.
DISCUSSION
This review synthesised the scientific literature for factors
associated with depression among adolescents in Singapore.
5
 Goh, et al.: Factors for adolescent depression in Singapore
Despite a modest yield of eight papers, the findings from
this review are reflective of the range of factors associated
with adolescent depression locally. The summaries of
recommendations are provided in Tables 4 and 5.
Sociocultural factors
Sociocultural factors play a significant role in terms of mental
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wellness.[39,40] A study of local adults has shown that Indians
have significantly higher rate of depression compared to
Chinese and Malays.[41] While Magiati et al.’s[30] paper did
not show any significant differences between Chinese, Indian
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and Malay primary school children in terms of self‑reported
depression, the tendency towards lower scores for depressive
symptoms among Chinese students compared to their Malay
and Indian counterparts may be related to the adversity
experienced by the ethnic minority groups[42] and possibly an
under‑reporting of symptoms of Chinese children in order to
avoid ‘loss of face’.[43]
In terms of gender, adolescent females have been observed to be
at a higher risk of depressive symptoms,[44‑46] attributable in part
to the pubertal changes in the hormone–brain relationship[47,48]
and to the emergence of received sociocultural gender roles
that may include the need to internalise symptoms[49] among
girls more than among boys.[50‑52] In this review, primary
school‑aged Indian girls were found to have higher scores for
emotional symptoms than Indian boys, which may be reflective
of the increasing influence of traditional gender roles during
adolescence.[53] Nonetheless, the full effects of sociocultural
differentiation on well‑being may not be well reflected in
Magiati et al.’s[30] paper as the school‑aged participants would
have just been at the cusp of assuming their sociocultural and
gender roles.
Adverse childhood events
The lifetime prevalence of adverse childhood events (ACE)
of Singapore residents aged 18 years and above is 63.9%.[54]
ACE and childhood maltreatment are associated with increased
risk of adolescent depression and mental disorders across
the lifespan.[55‑57] Postulated mechanisms include the scars of
increased self‑criticism, negative cognitive styles and the fear
of rejection later in life.[32] Peh et al.[32] identified emotional
dysregulation as a mediator between childhood maltreatment
exposure and the risk of self‑harm. Wong and Lim,[33] on the
other hand, explored the hope and optimism constructs and
their negative correlation with depression.[58,59] This concurs
with other studies which showed how lack of goal‑directed
energy (agency thinking) was more predictive of depression
than lack of pathway thinking.[60]
Chronic medical conditions
Our review found that poorly controlled asthma was associated
with a greater risk of depressive symptoms. This is consistent
with other studies which have found that at least one in four
adolescents with asthma have symptoms of depression, possibly
attributed, at least in part, to restrictions in daily functioning.[34]
6 Singapore Medical Journal ¦ Volume XX ¦ Issue XX ¦ Month 2023
Chronic conditions linked to adolescent depression in the
literature include insulin‑dependent diabetes mellitus[61,62] and
inflammatory bowel disease.[63,64] These point to the importance
of exploring the mental wellness of the adolescent patient who
presents at the clinic with poorly controlled asthma.
Sleep
Sleep is crucial for mental wellness, and the cumulative effects
of chronic partial sleep deprivation may adversely affect
mood and emotional regulation in adolescents.[65‑67] A nightly
sleep duration of 6 h or less increased the risk of depressive
symptoms and subsequent major depression. [68] Sleep
inadequacy and depression have a bidirectional relationship:
insomnia is both a symptom of depression[69] and a factor that
adversely affects the success of depression treatment.[70] Sleep
inadequacy may be perpetuated by the local school schedules[71]
that start 1 h earlier than the stated recommended start
time, according to the American Academy of Paediatrics,[72]
American Medical Association[73] and the American Academy
of Sleep Medicine.[74] This may be reflective of the East Asian
inclination to prioritise academic achievement over sleep, with
students often staying up late to finish uncompleted school
assignments.[75]
Excessive internet use
Touted as a smart city[76] with near‑total computer and internet
penetration (89% and 98% of households, respectively),[77]
Singapore has an adolescent population that widely uses the
internet and is adept at online gaming. However, excessive use
of the internet and pathological gaming are associated with
depressive symptoms. Both may spur a downward spiral that
compounds social isolation[78] and reinforces depression.
In a milieu that often values public self‑restraint[79,80] above
public self‑expression,[43,81‑85] the internet world provides a ready
means of escape from the restrictions of the real world.[43] As a
mediating factor between internet dependence and depression,
the tendency to internalise feelings may play a significant role in
the onset of depression and may be predictive of poorer mental
health and well‑being in middle adulthood.[86] So entwined is the
cyber world with the contemporary adolescent experience that
‘social media use’ has been added[87] to the HEADSSS tool[88,89]
to encourage practitioners to inquire about cyber wellness when
assessing the psychosocial risk of adolescents.
Conspicuously absent: academic stress and parental
expectations
Academic achievement is a prime preoccupation
in Singapore households. The consistent high national
ranking in the Programme for International Student
Assessment (PISA),[90,91] regular stellar performances in the
International Baccalaureate (IB) diploma programme[92] and
a thriving private supplementary tutoring mill, which starts
from the preschool years for some,[93] attest to this national
hyperfocus.[94] Though schoolwork was ranked by youths as
the most stressful aspect of their lives in a national survey,[95] it
 Goh, et al.: Factors for adolescent depression in Singapore

Table 4. Summary of recommendations based on intervention.

Factor Detection Recommendation
Mental Improved mental literacy in the Strengthen mental health literacy in the community, including parents, teachers, guardians, students,
health community (parents, teachers, adolescents. A community‑wide effort to strengthen mental health literacy may reduce mental health stigma
literacy adolescents) will reduce stigma and and aid in the early detection and treatment of depression in the community
allow for early detection of mental Train adolescents in emotional resilience/regulation. Programmes within schools include the SEL[118]
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illness items in schools. A wide range of programmes available to the public include the tMHFA and YMHFA,[125]
mindfulness‑based programmes and youth‑empowerment programmes
Skills in emotional regulation, coping with adversity and identifying maltreatment,[133,134] and identification and
modification of maladaptive cognitions/beliefs and behaviours can be taught to adolescents[135‑139]
Primary Primary care physicians should be Healthcare providers should be equipped for early detection and treatment of adolescent patients with mental
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care trained to develop a health index of health problems. This may include asking specific questions in the history, using the HEADSSS framework for
practitioner suspicion and detect depression risk health risk behaviour and mental health screening and using screening tools in the waiting area
among patients in the community Further mental health training opportunities include the GDMH and counselling skills
Sleep Screening for sleep deprivation or Adolescents should be asked about their sleep
poor sleep hygiene in adolescents Recommend a sleep duration of at least 6 h per night
Sleep enhancement: Sleep duration can be improved with adjustment of school start time, reduction of school
workload,[122] setting appropriate bedtime[123] and reinforcing sleep hygiene and parental training
Internet Screening for excessive internet use Limiting internet exposure: Parental limitation of internet usage and gaming and rescheduling sleep‑disrupting
use/ and gaming addiction media use at night.[140] Family therapy[141] forms as a great support system to prevent internet addiction in the
gaming future
Adolescents should be asked about internet use and use of social media. The HEADSSSS tool (with additional
S for social media) for screening can be used[87‑89]
Chronic Screening for concomitant Controlling chronic comorbidity: Adequate medical treatment for underlying medical comorbidity can reduce
disease depression in adolescents with discomfort and the risk of depression
underlying chronic disease Explore the mental health of patients with poorly controlled chronic disease
Known factors (not limited to) insulin‑dependent diabetes mellitus,[61,62] inflammatory bowel disease[63,64] and
asthma[34]
GDMH: graduate diploma in mental health, SEL: socio‑emotional learning, tMHFA: teen Mental Health First Aid, YMHA: Youth Mental Health First Aid

Table 5. Summary of recommendations based on factors.

Factor identified Subfactor Reference Recommendations
Sociodemographic Gender and ethnicity Magiati et al. Identifying those at risk for earlier detection of mental health issues
(2015)[30] Better mental health literacy: Greater advocacy for mental health awareness will aid in
early detection of depression and allow prompt treatment
Examples (not limited to): Teen and Youth Mental Health First Aid,[125] Silver
Ribbon,[127] SAMH[126]
Psychological Childhood maltreatment exposure Peh et al. Screening for emotional dysregulation or maltreatment history in adolescents to
(2017)[32] determine possible underlying depression risk
Psychological constructs (hope, Wong and Emotional resilience training: Skills in emotional regulation and coping with adversity
optimism) Lim (2009)[33] Examples (not limited to): REACH,[120,121] cultivating resilience,[129‑132] identifying
maltreatment,[133, 134] modification of cognition/beliefs and behaviour[135‑139]
Chronic medical Chronic medical conditions Lu et al. Screening for concomitant depression in adolescents with underlying chronic
condition (2014)[34] disease
Controlling chronic comorbidities: Adequate medical treatment for underlying medical
comorbidities can reduce discomfort and the risk of depression
Known factors (not limited to) insulin‑dependent diabetes mellitus,[61,62] inflammatory
bowel disease[63,64] and asthma[34]
Lifestyle Sleep duration Yeo et al. Screening for sleep deprivation or poor sleep hygiene in adolescents
(2019)[35] Sleep enhancement: Sleep duration can be improved with adjustment of school start
Lo et al. time, reduction of school workload,[122] setting appropriate bedtime,[123] reinforcing
(2018)[36] sleep hygiene and parental training
Recommended sleep duration: 6 h per night
Excessive internet use and Gentile et al.
Screening for excessive internet use and gaming addiction
related media (2011)[38]
Limiting internet exposure: Parental limitation of internet usage and gaming and
Mythily et al.
rescheduling sleep‑disrupting media use at night.[140] Family therapy[141] forms as a
(2008)[37]
great support system to prevent internet addiction in the future
HEADSSSS tool (with additional S for social media) for screening can be used[87‑89]
REACH: Response, Early interventions and Assessment in Community mental Health, SAMH: Singapore Association for Mental Health

Singapore Medical Journal ¦ Volume XX ¦ Issue XX ¦ Month 2023 7

 Goh, et al.: Factors for adolescent depression in Singapore
was surprising that academic stress was not explicitly studied
as a factor in the papers reviewed.
Closely linked to academic stress and equally conspicuous
because of its absence is the matter of parental expectations.
Different from Western households that may value social
development[96] no less than academic achievement, schooling
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may often be a major focus of family time, effort and source
of contention in East Asian households.[97‑99] Risk factors that
relate to parenting styles and depression include parental
overprotection,[100‑102] psychological control[103] and the teenage
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fear of being the source of parental disappointment.[104]
Compared to their European–American counterparts, Asian
parents tend to adopt an authoritarian parenting style[105,106]
that demands from children the commitment to hard work,
self‑discipline and obedience,[107] often measured by academic
performance. The adolescent tussle for autonomy in such
circumstances is a ground for distress and depression,[108]
and practitioners do well to provide guidance to parents on
the effects of parenting on adolescents’ well‑being. The high
reported rate of depression (CDI, 16.9%) in Magiati et al.’s[30]
paper, articles on sleep deprivation on school nights[109,110] and
their effects on school performance and depression,[66,67,111‑113]
as well as studies on excessive computer use[37,38] and their
adverse effects on school performance allude to the influential
role that parenting styles and academic stress play in adolescent
mental health in Singapore.
Comparison with our counterparts
Singapore is a multiethnic, multilingual society with coexisting
traditionally Asian and modern Westernised values, with risk
factors for depression largely similar to those reported in the
global literature.[114‑116] Despite Western influence, local mental
health literacy falls short of that other developed countries, with
a pervasive tendency to label depression as a ‘weakness’ caused
by lack of resilience,[39] rather than as a medical condition. With
influence from traditional Asian values, Singaporean children
tend to have higher rates of internalising problems compared
to externalising problems,[43] which is the opposite of that
seen in Western children, further deterring early detection of
adolescent depression.
Practical implications
This review underlies the need for an all‑of‑society effort to
address adolescent mental health. In addition to policy‑level
initiatives, this would include enlisting schools, social service
organisations (SSOs), psychological services, ground‑up
community efforts,[117] as well as the primary and hospital
specialist healthcare services as part of an overarching
evidence‑informed strategy to address youth mental wellness.
Sleep habits
Sleep deprivation is both a harbinger and symptom of distress
and depression. Primary care physicians should enquire about
the sleep patterns and sleep hygiene of an adolescent patient
during consultation, and encourage a healthy sleep routine.
8 Singapore Medical Journal ¦ Volume XX ¦ Issue XX ¦ Month 2023
Internet use
Adolescents and their parents who present at the clinic should
likewise be asked about the adolescent patient’s use of the
internet. Excessive internet use may prompt the need to screen
for distress, schoolwork and relationships, as well as depression
and other mental health problems. The accessibility of primary
care in the community makes it an excellent venue to enquire
about internet use and the adolescents’ experience of stress and
coping and to provide opportunistic advice on healthy gaming
and internet use, particularly for sleep‑deprived gamers.
Chronic disease
In our review, poor asthma control was found to be a risk for
adolescent depression. Given the bidirectional relationship
of chronic disease control and depression, the patient with
poor chronic disease control should as much be screened
for depressive symptoms[34,61‑64] as a patient with depressive
symptoms is asked about the control of his/her chronic disease
condition.
Mental health literacy
The strengthening of mental health literacy across all levels of
society — policymaking, school, parental/family and personal/
adolescent levels — facilitates the possibility of a collective
strengthening of emotional awareness and self‑regulation in the
community and earlier help‑seeking for mental health matters
among adolescents.
Educational efforts to address adolescent mental wellness
in our schools include socio‑emotional learning (SEL)[118]
in the Character and Citizenship Education (CCE) curricula
widely embedded in primary and secondary schools.[119] The
system of Response, Early interventions and Assessment in
Community mental Health (REACH)[120,121] team working
with school counsellors addresses the mental health issues that
may arise in the school setting.[117,120,121] In addition, improving
sleep through bold interventions, such as the adjustment of
school start times, a reduction of schoolwork,[122] a deliberate
setting of bedtimes,[123] reinforcement of good sleep hygiene
and parental education, plays an important role in adolescent
mental wellness.
At the community level, SSOs and ground‑up initiatives
provide a diverse range of community‑based youth services
and empowerment programmes for youth (e.g. Impart,[124]
mental health first aid (MHFA), [125] Project 180, [124]
Singapore Association for Mental Health (SAMH), [126]
Silver Ribbon,[127] TOUCH Youth Intervention[128]). They
equip adolescents with the skills to cope with adversity,
cultivate resilience,[129‑132] identify maltreatment,[133,134] modify
maladaptive cognitions [135‑139] and address pathological
Internet use; also, they provide interventions to reduce sleep
disruption[140] and family therapy[141] if and when required. Teen
Mental Health First Aid (tMHFA) and Youth Mental Health
First Aid (YMHFA) are programmes that have been shown to
be effective in improving mental health literacy.[125]
 Goh, et al.: Factors for adolescent depression in Singapore
Role of primary care
Noticeably absent in this review was the role of primary care
in supporting adolescent mental health. Perhaps the body
of work of primary care physicians in managing adolescent
mental health has been left largely unpublished. As the first port
of call for patients in the community, primary care physicians
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in the polyclinics and the approximately 2,000 primary care
clinics in private practice should be equipped for the early
detection and prompt intervention of adolescent depression
when necessary. Local training opportunities for primary care
YQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 03/14/2024
physicians include the Graduate Diploma in Mental Health,
and other programmes such as positive psychology, cognitive
behavioural therapy and other counselling skills. Primary care
physicians also need to be connected to local resources, such
as family service centres which may provide counselling and
therapy services to clients.
Recommendations for research
This review points to further areas of research in adolescent
mental health. Well‑designed interventional studies to improve
sleep, address excessive internet use, improve the emotional
resilience and mental health literacy of adolescents, and
studies that venture to modify parenting styles and/or address
academic stress may be of value. Research may also branch
into factors associated with depression that were not surfaced
in this review, such as adolescent temperament,[142] social
isolation and loneliness,[143] peer rejection,[144] parental history
of depression,[145,146] poor parent–child relationship,[147] poor
family attachment and detachment from family activities.[148,149]
On a backdrop of the 2008 WHO/WONCA joint report
recommending the greater integration of mental health in
primary care,[150] the potential for primary care involvement in
adolescent mental health is notable. As mental illness remains
largely undetected even in patients seeking medical help, there
is value in reducing the missed opportunities for early detection
and management of mental illness for adolescents who show
up at primary care clinics in the community, especially since
onset during adolescence is more frequent.
A health services research agenda to improve the mental health
of adolescents in Singapore should start with a mapping of
the extent that primary and secondary health care is involved
in adolescent mental health detection and management.
Interventions such as practitioner training, the strengthening of
partnerships between primary and secondary care, and the use
of screening questionnaires and technological innovations[151,152]
that have shown promise elsewhere to improve mental illness
detection at primary care may, subsequently be planned.
CONCLUSION
The results of the eight studies included in this review serve to
prompt healthcare practitioners to further explore the mental
wellness of adolescent patients in the clinic. In addition,
they underline the importance of an all‑of‑society effort to
Singapore Medical Journal ¦ Volume XX ¦ Issue XX ¦ Month 2023
strengthen mental health literacy in the population to stem the
inordinate number of teen suicides seen in recent years. Health
services research in adolescent mental health that enlists the
extensive reach and care continuity characteristic of primary
care in collaboration with paediatricians and psychiatrists
shows promise for developing a home‑grown evidence base
for the improved mental health outcomes of adolescents in
Singapore.
Acknowledgement
We would like to acknowledge Ms Monica Ashwini Lazarus,
Research Associate, and Dr Miny Samuel, Assistant Director,
Dean’s Office (Research) from Yong Loo Lin School of
Medicine, National University of Singapore for their support.
Financial support and sponsorship
Nil.
Conflicts of  interest
There are no conflicts of interest.
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 APPENDIX

Search strategy and results

A search was conducted on 4th April 2020 on PubMed (94), Embase (116), and PsycINFO (18).
Downloaded from http://journals.lww.com/smj by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWn

Supplementary Table 1. PubMed

No. Searches Results

#1 ("Depression"[Mesh] OR "Depressive Disorder"[Mesh]) OR 431,555

YQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 03/14/2024

(“Depressi*”[title/abstract] OR “MDD”[title/abstract] OR
“Dysthymia”[Title/Abstract] OR “Dysthymic disorder”[Title/Abstract])

#2 ("Adolescent"[Mesh] OR “Child”[Mesh]) OR 308,2035

(“Adolescent*”[title/abstract] OR “adolescence”[title/abstract] OR
“teen*”[title/abstract] OR “youth*”[title/abstract])

#3 ("Singapore"[Mesh]) OR ("Singapore*"[Title/Abstract]) 19,344

#4 "Factor*"[Title/Abstract] OR "associat*"[Title/Abstract] OR 960,0393

"relationship*"[Title/Abstract] OR “predict*”[Title/Abstract] OR
“prevalence”[Title/Abstract] OR “course”[Title/Abstract] OR
“prognos*”[Title/Abstract] OR “Cause”[Title/Abstract] OR
“Etiolog*”[Title/Abstract] OR “Aetiolog*”[Title/Abstract]

#5 #1 AND #2 AND #3 AND #4 94

Supplementary Table 2. Embase

No. Searches Results

#1 'depression'/exp OR 'depressi*':ti,ab OR 'mdd':ti,ab OR 'dysthymia':ti,ab 704,475

OR 'dysthymic disorder':ti,ab

#2 'adolescent'/exp OR 'child'/exp OR 'adolescent*':ti,ab OR 377,4927

'adolescence':ti,ab OR 'teen*':ti,ab OR 'youth*':ti,ab

#3 'singapore'/exp OR 'singapore*':ti,ab 29,976

#4 'factor*':ti,ab OR 'associat*':ti,ab OR 'relationship*':ti,ab OR 12,460,808

'predict*':ti,ab OR 'prevalence':ti,ab OR 'course':ti,ab OR 'prognos*':ti,ab
OR 'cause':ti,ab OR 'etiolog*':ti,ab OR 'aetiolog*':ti,ab

#5 #1 AND #2 AND #3 AND #4 116

 Supplementary Table 3. PsycINFO
No. Searches Results

#1 (Depressi* OR MDD OR Dysthymia OR Dysthymic disorder).ti,ab. 284,185

Downloaded from http://journals.lww.com/smj by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWn

#2 (Adolescent* OR adolescence OR teen* OR youth*).ti,ab. 301,282

#3 Singapore*.ti,ab. 4,269
YQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 03/14/2024

#4 (Factor* OR associat* OR Relationship* OR Predict* OR Prevalence OR 2,123,263

Course OR Prognos* OR Cause OR Etiolog* OR Aetiolog*).ti,ab.

#5 #1 AND #2 AND #3 AND #4 18