Journal of Affective Disorders 354 (2024) 553–562

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Journal of Affective Disorders

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

Research paper

Global burden of depression or depressive symptoms in children and

adolescents: A systematic review and meta-analysis
Bingqing Lu a, *, Lixia Lin b, Xiaojuan Su c
a
Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu 610075, China
b
School of Physical Education and Health, Hubei University of Chinese Medicine, Wuhan 430065, China
c
Chengdu University of Traditional Chinese Medicine, Chengdu 610075, China

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

Keywords: Background: Depression is the leading cause of health-related disability. A proportion of depression cases begin in
Children childhood and increase dramatically during adolescence. This systematic review and meta-analysis aimed to
Adolescents estimate the global prevalence of depression or depressive symptoms in children and adolescents and explore the
Depression
temporal and regional distribution of depression or depressive symptoms.
Systematic review
Methods: This systematic review and meta-analysis identified peer-reviewed literature published through April 8,
Meta-analysis
2023, using the MEDLINE, Embase and APA PsycINFO databases, supplemented by reverse reference searches.
Observational studies published in English and based on validated instruments with prevalence data on
depression or depressive symptoms in children and adolescents aged ≤18 years were eligible. Random-effects
meta-analysis and meta-regression analysis were performed using R software.
Results: This systematic review and meta-analysis included a total of 96 studies (29 countries, 528,293 partici­
pants) published between 1989 and 2022. The pooled prevalence of mild-to-severe, moderate-to-severe, and
major depression were 21.3 % (95%CI, 16.7 %–26.7 %), 18.9 % (95%CI, 14.6 %–24.2 %), and 3.7 % (95%CI, 2.7
%–5.1 %) respectively. Meta-regression analysis showed that from 1989 to 2022, the prevalence of mild-to-
severe and moderate-to-severe depression increased over time (P = 0.002, P = 0.034, respectively), but the
prevalence of major depression did not change significantly (P = 0.636).
Limitations: Only English articles were included. There was significant heterogeneity across the included studies.
The studies included were mostly based on self-report scales to assess depressive symptoms.
Conclusion: In this systematic review, about one in five children and adolescents globally suffered from
depression or had depressive symptoms, and this proportion was increasing over time.

1. Introduction depression within the course of 12-months (Herrman et al., 2022).

In contrast to sadness, which most people experience from time to
time, and despair or pain experienced during adversity, depression is a
mental health condition (Herrman et al., 2022). Depression causes
profound, lasting suffering for those affected and is associated with
premature death from physical illness and suicide (Wright et al., 2021).
Beyond the individual, depression also affects families and communities,
impairing social functioning and economic productivity (Dwyer et al.,
2020; Philipson et al., 2020). Depression is the leading cause of health-
related disability and a major contributor to the global disease burden
(Collaborators, 2018; Korczak et al., 2023; Krause et al., 2021).
Approximately 4.7 % of the world’s population experience an episode of
However, policy attention and resources are woefully inadequate. Even
in high-income countries, <20 % of patients with major depression
receive effective care, and in low- and middle-income countries, this
proportion is <10 % (Vigo et al., 2020).
A proportion of depression cases begin in childhood and increase
dramatically during adolescence (Korczak et al., 2023; Morken et al.,
2021). By 19 years old, an estimated 25 % of teenagers have experienced
a depressive episode, according to research (Hetrick et al., 2021).
Depressive episodes in pre-adulthood often predict relationship chal­
lenges, academic and career difficulties, poor quality of life, and more
physical and mental illness, as well as more depressive episodes and a
higher risk of self-harm and suicide (Fitzpatrick et al., 2023; Hawrilenko

* Corresponding author at: Hospital of Chengdu University of Traditional Chinese Medicine, No.39, Shierqiao Road, Jinniu District, Chengdu 610075, China.
E-mail address: lubingqing2018@163.com (B. Lu).

https://doi.org/10.1016/j.jad.2024.03.074
Received 24 December 2023; Received in revised form 6 March 2024; Accepted 10 March 2024
Available online 14 March 2024
0165-0327/© 2024 Elsevier B.V. All rights reserved.
B. Lu et al.
Fig. 1. PRISMA flowchart.
et al., 2021; Hetrick et al., 2021). In adolescents, subthreshold depres­
sion is more common than diagnostic threshold depressive disorders,
with prevalence twice as high (Gee et al., 2020; Noyes et al., 2022). A
recent systematic review found that subthreshold depression is similar
to major depressive disorder in terms of functional impairment, brain
changes, suicidal ideation, comorbidity, and genetic predisposition,
emphasizing that subthreshold depression also has important clinical
implications (Noyes et al., 2022). Therefore, early identification and
intervention of depression in children and adolescents is regarded as a
global health priority and public health challenge (Davaasambuu et al.,
2020; Eckshtain et al., 2020; Miller and Campo, 2021).
Most of the recent systematic reviews reporting on the prevalence of
depression or depressive symptoms in children or adolescents focused
on one country (Mahmudi et al., 2021; Wang et al., 2019) or special
group (e.g., obese children, cancer patients) (Al-Saadi et al., 2022;
Barker et al., 2019; Chen et al., 2023), and two systematic reviews
covering the world also had some limitations, including: less rigorous
studies were included (Shorey et al., 2022); only studies reporting on at
least three mental disorders were included (Polanczyk et al., 2015). To
our knowledge, there are no studies that provide a comprehensive re­
view of the global burden of depression or depressive symptoms in
children and adolescents.
The purpose of this systematic review and meta-analysis is to esti­
mate the global burden of depression or depressive symptoms (hereafter
depression) in children and adolescents based on currently available
high-quality evidence, and to provide its temporal and regional distri­
bution to help policymakers assess the scope and severity of this problem
554
Journal of Affective Disorders 354 (2024) 553–562
and focus on the far unmet mental health needs of children and
adolescents.
2. Methods
2.1. Protocol and registration
Our reporting followed the Meta-analyses of Observational Studies in
Epidemiology (MOOSE) guidelines (Stroup et al., 2000) (Supplementary
Table 1) and the Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) guidelines (Moher et al., 2009) (Supplemen­
tary Table 2). The protocol was registered in PROSPERO
(CRD42023453622).
2.2. Search strategy
This systematic review and meta-analysis focused on studies per­
taining to the prevalence of depression among children and adolescents.
We systematically searched for peer-reviewed literature using MEDLINE
(Ovid), Embase (Ovid), and APA PsycINFO (Ovid) up to April 8, 2023
(search terms used are detailed in Supplementary Table 3). Additionally,
we also hand-searched references of identified articles and earlier re­
views to identify additional publications. The literature search was
restricted to English language.
B. Lu et al. Journal of Affective Disorders 354 (2024) 553–562

2.3. Eligibility criteria Event Total [95% CI] Prevalence (95% CI)

BDI−II 14
Latefa 2018 1239 2330 0.532 [0.511; 0.552]

Studies were included if they met the following criteria: (1) were
Syed 2021 89 518 0.172 [0.140; 0.207]
Sahibzada 2021 40 208 0.192 [0.141; 0.253]
Total (95% CI) 3056 0.278 [0.116; 0.531]

cross-sectional surveys or baseline survey of cohort studies, (2) surveyed Heterogeneity: Tau2 = 0.891; Chi2 = 246.85, df = 2 (P < 0.01); I2 = 99.19%

the general youth population aged ≤18, (3) selected the respondents
CBCL
Lin 2021 163 12186 0.013 [0.011; 0.016]

from a reliable framework (e.g., individuals, schools or households), (4) CDI 13

Larsson 1992 47 467 0.101 [0.075; 0.132]

evaluated depression with a validated method, (5) reported point CDI 17

prevalence or sufficient information to estimate point prevalence, (6)

Josepa 1995 50 534 0.094 [0.070; 0.122]
Fredrik 1999 381 5685 0.067 [0.061; 0.074]

published in peer-reviewed journals, and (7) published in English. To

Andre 2004 73 811 0.090 [0.071; 0.112]
Sujin 2006 396 1187 0.334 [0.307; 0.361]
Luciano 2010 24 1039 0.023 [0.015; 0.034]

ensure sample representativeness and comparability across estimates, Total (95% CI) 9256 0.089 [0.036; 0.203]
Heterogeneity: Tau2 = 1.173; Chi2 = 672.56, df = 4 (P < 0.01); I2 = 99.41%

the following studies were excluded: (1) adopted non-probabilistic CDI 18

sampling at the individual level, (2) response rate at the individual

Keng 2019 70 327 0.214 [0.171; 0.263]

CDI 19

level < 80 %, (3) used only clinical records for diagnosis, and (4) re­ Aquilino 1993
Yanping 2007
471
513
6432
3886
0.073 [0.067; 0.080]
0.132 [0.122; 0.143]

ported data only for male or female.

Said 2009 754 7602 0.099 [0.093; 0.106]
George 2009 23 548 0.042 [0.027; 0.062]
Turkay 2011 172 1482 0.116 [0.100; 0.133]
Hongli 2014 355 3096 0.115 [0.104; 0.126]
Maggi 2014 38 237 0.160 [0.116; 0.213]

2.4. Study selection and data extraction Maggi 2014

Joyce 2016
30
109
241
519
0.124 [0.086; 0.173]
0.210 [0.176; 0.248]
Lifei 2016 2550 10657 0.239 [0.231; 0.247]
Total (95% CI) 34700 0.121 [0.089; 0.163]
Heterogeneity: Tau2 = 0.293; Chi2 = 1178.56, df = 9 (P < 0.01); I2 = 99.24%

References were imported into endnote (Philadelphia, version X9). CDI 20

After removing duplicates, two reviewers (Bingqing Lu and Xiaojuan Su)

Xin 2009 384 2444 0.157 [0.143; 0.172]
Ade 2011 62 1100 0.056 [0.043; 0.072]

independently screened articles by title and abstract followed by full text

Min 2015 281 2283 0.123 [0.110; 0.137]
Jieyu 2022 190 1353 0.140 [0.122; 0.160]

and independently extracted data from eligible studies, including

Total (95% CI) 7180 0.113 [0.072; 0.173]
Heterogeneity: Tau2 = 0.244; Chi2 = 66.92, df = 3 (P < 0.01); I2 = 95.52%

author, publication year, study location, survey year(s), sampling frame,

CES−D 16
Robert 1995 944 2217 0.426 [0.405; 0.447]

sample size, age range, male percentage, measurement instrument, and

Martha 2003 1141 3261 0.350 [0.334; 0.367]
Anise 2016 5412 9518 0.569 [0.559; 0.579]

prevalence estimate of depression. Disagreements were discussed with a

Huisi 2017 1041 6406 0.163 [0.154; 0.172]
Truc 2022 673 1492 0.451 [0.426; 0.477]
Lipeng 2022 5767 11831 0.487 [0.478; 0.496]

third reviewer (Lixia Lin) until consensus was reached. We searched for
Total (95% CI) 34725 0.396 [0.278; 0.528]
Heterogeneity: Tau2 = 0.442; Chi2 = 2538.13, df = 5 (P ); I2 = 99.8%

related publications when information was missing or unclear. CES−D 17

Mi 2018 544 2679 0.203 [0.188; 0.219]

CES−D−12 12

2.5. Quality assessment

Sunday 2014 2773 8812 0.315 [0.305; 0.324]

CES−DC 15
Malakeh 2017 590 800 0.738 [0.706; 0.768]

Two reviewers (Bingqing Lu and Lixia Lin) used The Joanna Briggs CES−DC 16
Ayesha 2015 2063 3509 0.588 [0.571; 0.604]

Institute Checklist for Prevalence Studies (Munn et al., 2015) to inde­ CESD−R 16

pendently evaluate study quality, and disagreement was decided by

Besi 2020 150 1057 0.142 [0.121; 0.164]

Childhood depression scale 19

consensus. This checklist includes nine evaluation criteria. One point Omer 2015 810 5355 0.151 [0.142; 0.161]

was awarded per criteria met, with a maximum of nine points, and more
CSSSDS 2
Ren 2019 614 3081 0.199 [0.185; 0.214]

than four points was considered high study quality. DASS−21 10

Ensiyeh 2021 1512 2852 0.530 [0.512; 0.549]
Anh 2021 223 712 0.313 [0.279; 0.349]
Suqin 2020 857 4342 0.197 [0.186; 0.210]

2.6. Data synthesis

Benli 2022 14839 42077 0.353 [0.348; 0.357]
Balan 2018 249 461 0.540 [0.493; 0.586]
Total (95% CI) 50444 0.377 [0.253; 0.518]
Heterogeneity: Tau2 = 0.429; Chi2 = 884.17, df = 4 (P < 0.01); I2 = 99.55%

We used inverse variance weighted random-effects models to pool DASS−42 9

Azar 2016 288 673 0.428 [0.390; 0.466]

the logit-transformed prevalence of depression of different severity DSRS 16

(mild-to-severe, moderate-to-severe, or major depression). To avoid

Reiji 2019 112 904 0.124 [0.103; 0.147]

DSRS−C 16

double counting, the meta-analysis only included the estimate with the Hui 2011
Fanghong 2013
1191
266
5003
3155
0.238 [0.226; 0.250]
0.084 [0.075; 0.095]

largest analytical sample when multiple publications reported the same

Michio 2018 1642 8209 0.200 [0.191; 0.209]
Total (95% CI) 16367 0.162 [0.085; 0.287]

research. Heterogeneity across the studies was assessed using the I2

Heterogeneity: Tau2 = 0.419; Chi2 = 287.45, df = 2 (P < 0.01); I2 = 99.3%

GHQ−12 3/4

statistic. To explore potential sources of heterogeneity, subgroup anal­ Yoko 2017 6073 17451 0.348 [0.341; 0.355]

ysis was conducted using measurement instruments, countries, World

GHQ−28 7
Katayoun 2018 398 1202 0.331 [0.305; 0.359]

Bank income classifications (low-income, lower-middle-income, upper- HADS 7

Amna 2018 494 1124 0.440 [0.410; 0.469]

middle-income, high-income countries), and age (<10 years, 10–18 HSCL−10 18.5

years) where possible, and maps were used to present the pooled prev­
Ole 2004 1319 7329 0.180 [0.171; 0.189]

alence estimates of depression in different countries. To explore the time

KID IO "B1" 7
Jacek 2008 388 1577 0.246 [0.225; 0.268]

trend of depression prevalence, we conducted meta-regression analysis

MFQ 26
Anne 2011 231 2421 0.095 [0.084; 0.108]

of depression prevalence by survey time. Begg’s test and funnel plots PFC 3

were used to assess the presence of publication bias. Sensitivity analyses

Pia 2013 37 653 0.057 [0.040; 0.077]

PHQ−9 5

were conducted by excluding each study from the pooled estimates to

Muwada 2019 346 388 0.892 [0.857; 0.921]
Afifa 2021 1418 2313 0.613 [0.593; 0.633]

identify the impact of individual studies on the findings. In post-hoc

Md. Saiful 2021 394 563 0.700 [0.660; 0.737]
Total (95% CI) 3264 0.756 [0.540; 0.891]
Heterogeneity: Tau2 = 0.720; Chi2 = 103.06, df = 2 (P < 0.01); I2 = 98.06%

sensitivity analysis, we excluded studies from the country with the PHQ−9 (Customized)

largest number of studies (China) to further assess the robustness of the

Zinn 2008 54 724 0.075 [0.057; 0.096]

pooled estimates. All statistical analyses were performed in R (version

RADS 77
Candice 2000 184 1299 0.142 [0.123; 0.162]

4.2.2). Values of P < 0.05 were considered statistically significant. Total (95% CI) 232622 0.213 [0.167; 0.267]
Heterogeneity: Tau2 =1.378; Chi2 =23428.01, df = 59 (P 0 ); I2 = 99.75%
Test for subgroup differences: Chi2 = 6547.54, df = 28 (P ) 0 0.2 0.4 0.6 0.8 1
Prevalence of depression

3. Results
Fig. 2. Forest plot of prevalence of mild-to-severe depression with subgroup
analysis by measurement instrument.
2793 records were retrieved through initial database searching. After
removing duplicates, 2443 articles were screened. 1932 articles were
excluded after title and abstract review, 403 were excluded after full-
text review, and the remaining 108 met the eligibility criteria. Seven

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B. Lu et al. Journal of Affective Disorders 354 (2024) 553–562

Event Total [95% CI] Prevalence (95% CI)

BDI 16
Larsson 1991 54 605 0.089 [0.068; 0.115]
Renata 2010 480 1798 0.267 [0.247; 0.288]
Moon 2012 839 4899 0.171 [0.161; 0.182]
Total (95% CI) 7302 0.164 [0.086; 0.291]
Heterogeneity: Tau2 = 0.417; Chi2 = 116.21, df = 2 (P < 0.01); I2 = 98.28%

BDI−C 16
Olsson 1999 284 2300 0.123 [0.110; 0.138]

BDI−II 20
Latefa 2018 812 2330 0.348 [0.329; 0.368]
Syed 2021 42 518 0.081 [0.059; 0.108]
Sahibzada 2021 13 208 0.062 [0.034; 0.105]
Total (95% CI) 3056 0.130 [0.039; 0.352]
Heterogeneity: Tau2 = 1.266; Chi2 = 162.65, df = 2 (P < 0.01); I2 = 98.77%

BDI−13 8
Ann−Mari 2002 1261 15965 0.079 [0.075; 0.083]
Sari 2005 328 3278 0.100 [0.090; 0.111]
Total (95% CI) 19243 0.089 [0.070; 0.111]
Heterogeneity: Tau2 = 0.032; Chi2 = 15.87, df = 1 (P < 0.01); I2 = 93.7%

CES−D 20
Wenzhe 2021 1393 4100 0.340 [0.325; 0.354]

CES−D 21
Anise 2016 3970 9518 0.417 [0.407; 0.427]
Cai 2022 133 678 0.196 [0.167; 0.228]
Total (95% CI) 10196 0.296 [0.128; 0.546]
Heterogeneity: Tau2 = 0.574; Chi2 = 118.26, df = 1 (P < 0.01); I2 = 99.15%

CES−D 24
Robert 1995 570 2217 0.257 [0.239; 0.276]
Mi 2018 137 2679 0.051 [0.043; 0.060]
Total (95% CI) 4896 0.120 [0.022; 0.458]
Heterogeneity: Tau2 = 1.724; Chi2 = 343.97, df = 1 (P < 0.01); I2 = 99.71%

CES−D (Male 21, Female 23)

Joseph 2001 70 1340 0.052 [0.041; 0.066]

CES−D−12 21
Sunday 2014 710 8812 0.081 [0.075; 0.086]

DASS−21 14
Jasvindar 2014 4373 24708 0.177 [0.172; 0.182]
Lawrence 2014 248 1678 0.148 [0.131; 0.166]
Latiffah 2016 1245 2927 0.425 [0.407; 0.443]
LeeAnn 2019 4764 26809 0.178 [0.173; 0.182]
Truc 2020 428 1075 0.398 [0.369; 0.428]
Ensiyeh 2021 747 2852 0.262 [0.246; 0.278]
Total (95% CI) 60049 0.251 [0.169; 0.354]
Heterogeneity: Tau2 = 0.380; Chi2 = 1347.45, df = 5 (P < 0.01); I2 = 99.63%

HADS 10
Amna 2018 193 1124 0.172 [0.150; 0.195]

PHQ−9 10
Fiorela 2017 167 840 0.199 [0.172; 0.227]
Normala 2017 577 1765 0.327 [0.305; 0.349]
Muwada 2019 209 388 0.539 [0.488; 0.589]
Afifa 2021 696 2313 0.301 [0.282; 0.320]
Md. Saiful 2021 149 563 0.265 [0.229; 0.303]
Total (95% CI) 5869 0.317 [0.220; 0.433]
Heterogeneity: Tau2 = 0.316; Chi2 = 143.74, df = 4 (P < 0.01); I2 = 97.22%

Total (95% CI) 128287 0.189 [0.146; 0.242]

Heterogeneity: Tau2 = 0.709; Chi2 =8119.30, df = 27 (P 0 ); I2 = 99.67%
Test for subgroup differences: Chi2 = 1445.75, df = 11 (P < 0.01) 0 0.1 0.2 0.3 0.4 0.5 0.6
Prevalence of depression

Fig. 3. Forest plot of prevalence of moderate-to-severe depression with subgroup analysis by measurement instrument.

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B. Lu et al. Journal of Affective Disorders 354 (2024) 553–562

S Event Total [95% CI] Prevalence (95% CI)

BDI−II 29
Latefa 2018 361 2330 0.155 [0.140; 0.170]
Syed 2021 13 518 0.025 [0.013; 0.043]
Total (95% CI) 2848 0.065 [0.010; 0.324]
Heterogeneity: Tau2 = 1.886; Chi2 = 46.9, df = 1 (P < 0.01); I2 = 97.87%

CES−D 29
Chilin 2008 1179 9586 0.123 [0.116; 0.130]
Lan 2014 205 3186 0.064 [0.056; 0.073]
Mi 2018 51 2679 0.019 [0.014; 0.025]
Wanxin 2021 169 1894 0.089 [0.077; 0.103]
Total (95% CI) 17345 0.062 [0.028; 0.132]
Heterogeneity: Tau2 = 0.721; Chi2 = 253.73, df = 3 (P < 0.01); I2 = 98.82%

CES−D 30
Carol 1992 173 3283 0.053 [0.045; 0.061]

CES−D 31
Robert 1995 346 2217 0.156 [0.141; 0.172]

DASS−21 21
Ensiyeh 2021 205 2852 0.072 [0.063; 0.082]

PHQ−9 20
Afifa 2021 79 2313 0.034 [0.027; 0.042]
Md. Saiful 2021 19 563 0.034 [0.020; 0.052]
Total (95% CI) 2876 0.034 [0.028; 0.041]
Heterogeneity: Tau2 = 0; Chi2 = 0, df = 1 (P = 0.96); I2 = 0%

DSD
Robert 1997 456 5423 0.084 [0.077; 0.092]

CIDI
Shelli 2015 777 10123 0.077 [0.072; 0.082]

CIS−R
Konstantina 2015 246 5614 0.044 [0.039; 0.050]

DAWBA
Tamsin 2003 94 10438 0.009 [0.007; 0.011]
Sandra 2014 46 3585 0.013 [0.009; 0.017]
Xiaoli 2014 110 8488 0.013 [0.011; 0.016]
Total (95% CI) 22511 0.011 [0.009; 0.014]
Heterogeneity: Tau2 = 0.034; Chi2 = 7.74, df = 2 (P = 0.02); I2 = 74.15%

DISC−2.25/Dominic Questionnaire
Marie 1999 82 2400 0.034 [0.027; 0.042]

DISC−IV
Michael 2001 108 3597 0.030 [0.025; 0.036]
Glorisa 2004 68 1897 0.036 [0.028; 0.045]
Total (95% CI) 5494 0.032 [0.027; 0.038]
Heterogeneity: Tau2 = 0.004; Chi2 = 1.35, df = 1 (P = 0.24); I2 = 26.13%

DSM−III
Jan 1989 126 2386 0.053 [0.044; 0.063]

K−SADS−E
Susan 2005 7 1070 0.007 [0.003; 0.013]

K−SADS−PL
Sukanto 2012 58 1851 0.031 [0.024; 0.040]
Gul 2018 110 5834 0.019 [0.016; 0.023]
Mohammad 2019 521 28611 0.018 [0.017; 0.020]
Total (95% CI) 36296 0.022 [0.016; 0.030]
Heterogeneity: Tau2 = 0.080; Chi2 = 15.7, df = 2 (P < 0.01); I2 = 87.26%

MINI−KID
Yuan 2015 375 19711 0.019 [0.017; 0.021]

MINI−KID + DSM−IV interview

Fenghua 2021 2316 71929 0.032 [0.031; 0.034]

Total (95% CI) 214378 0.037 [0.027; 0.051]

Heterogeneity: Tau2 = 0.724; Chi2 = 4567.51, df = 26 (P 0 ); I2 = 99.43%
2
Test for subgroup differences: Chi = 1779.35, df = 16 (P ) 0 0.1 0.2 0.3 0.4
Prevalence of major depression

Fig. 4. Forest plot of prevalence of major depression with subgroup analysis by measurement instrument.

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B. Lu et al.
Fig. 5. Meta-regression analysis of depression prevalence by survey time. (a)
mild-to-severe depression, (b) moderate-to-severe depression, (c)
major depression.
additional articles were identified through reference review. After
excluding studies with overlapping samples, 96 studies involving
528,293 participants were ultimately included (Fig. 1). The reference
list of the studies included is provided in the Supplementary Material.
3.1. Characteristics of included studies
The included 96 studies were published between 1989 and 2022 and
conducted in 29 countries (26 in China, 6 in the USA, 6 in Malaysia, 4 in
Finland, 4 in Turkey, 4 in Iran, 4 in Vietnam, 3 in Sweden, 3 in Australia,
3 in Brazil, 3 in Canada, 3 in Japan, 3 in India, 2 in Spain, 2 in Norway, 2
in South Korea, 2 in Poland, 2 in Greece, 2 in Jordan, 2 in Pakistan, 2 in
Bangladesh, one each for Nigeria, Germany, Malawi, Uganda, Peru,
Sudan, United Arab Emirates, and United Kingdom). The median num­
ber of participants per study was 2393 (range, 208–71,929), and par­
ticipants ranged in age from 4 to 18. Of the 96 studies, 81 used self-
reported scales to assess depressive symptoms, and 15 used in­
terviews. 60 studies reported the prevalence estimate of mild-to-severe
depression, 28 reported the prevalence estimate of moderate-to-severe
depression and 27 reported the prevalence estimate of major
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Journal of Affective Disorders 354 (2024) 553–562
depression. Supplementary Tables 4 and 5 provide detailed information
on the included studies.
All included studies passed quality assessment according to the
Joanna Briggs Institute checklist, scoring from 5 to 9 (Supplementary
Table 6).
3.2. Prevalence of depression
Random-effects models were used to pool the prevalence of mild-to-
severe, moderate-to-severe, and major depression. Sixty studies esti­
mated the prevalence of mild-to-severe depression among 232,622
children and adolescents based on 15 self-reported scales and their re­
visions, with the most commonly used scale being the Children’s
Depression Inventory (CDI, n = 21). The pooled prevalence of mild-to-
severe depression was 21.3 % (95%CI, 16.7 %–26.7 %; I2 = 99.75 %)
(Fig. 2).
Twenty-eight studies estimated the prevalence of moderate-to-severe
depression among 128,287 children and adolescents based on 5 self-
reported scales and their revisions, with the most commonly used
scale being the Beck Depression Inventory (BDI, n = 9). The pooled
prevalence of moderate-to-severe depression was 18.9 % (95%CI, 14.6
%–24.2 %; I2 = 99.67 %) (Fig. 3).
Twenty-seven studies estimated the prevalence of major depression
among 214,378 children and adolescents based on 5 self-reported scales
and 9 interviews, among which Center for Epidemiologic Studies
Depression Scale (CES–D, n = 6) was the most used scale and Kiddie
Schedule for Affective Disorders and Schizophrenia (K-SADS, n = 4) was
the most used interview. The pooled prevalence of major depression was
3.7 % (95%CI, 2.7 %–5.1 %; I2 = 99.43 %) (Fig. 4).
Considering the heterogeneity of the results, we conducted subgroup
analysis by measurement instrument and cut-off point, and the results
showed that subgroup effects were statistically significant (P < 0.001, P
< 0.01, P < 0.001, respectively). Variance between studies was high in
subgroups with the same measurement instruments and cut-off points.
Except for two subgroups, PHQ-9 ≥ 20 (I2 = 0 %) and DISC-IV (I2 =
26.13 %), the remaining subgroups had I2 >70 %.
3.3. Temporal trends in depression
From 1989 to 2022, the estimated prevalence of mild-to-severe, and
moderate-to-severe depression among children and adolescents in 29
countries increased (P = 0.002, P = 0.034, respectively) (Fig. 5a and b).
In contrast, the estimated prevalence of major depression decreased
during this period, but there was no statistical significance (P = 0.636)
(Fig. 5c).
3.4. Distribution of depression among countries
Fig. 6 shows the prevalence of mild-to-severe depression, moderate-
to-severe depression, and major depression in different countries.
Overall, the prevalence of depression varies from country to country.
Sixty studies evaluated mild-to-severe depression in 26 countries, with
prevalence ranging from 4.2 % (95 % CI, 2.7 % -6.2 %) in Germany to
70.0 % (95 % CI, 66.0 % -73.7 %) in Australia. Twenty-eight studies
evaluated moderate-to-severe depression in 17 countries, with preva­
lence ranging from 5.2 % (95 % CI, 4.1 % -6.6 %) in Australia to 53.9 %
(95 % CI, 48.8 % -58.9 %) in Sudan. Twenty-seven studies evaluated
major depression in 13 countries, with prevalence ranging from 0.9 %
(95 % CI, 0.7 % -1.1 %) in the UK to 15.5 % (95 % CI, 14.0 % -17.0 %) in
Jordan. The forest plots of depression prevalence in different countries
are shown in Supplementary Fig. 1–3.
3.5. Distribution of depression among income groups
Prevalence estimates of mild-to-severe depression in high-income,
upper-middle-income, lower-middle-income, and low-income
B. Lu et al. Journal of Affective Disorders 354 (2024) 553–562

Fig. 6. Prevalence of depression among children and adolescents across countries. (a) mild-to-severe depression, (b) moderate-to-severe depression, (c)
major depression.

559
B. Lu et al. Journal of Affective Disorders 354 (2024) 553–562

Table 1 3.6. Age distribution of depression

Prevalence estimates of mild-to-severe depression across four income groups.
Income group No. of Pooled 95%CI Subgroup Table 4 shows the pooled prevalence of depression in children under
studies prevalence (%) differences 10 years and adolescents aged 10–18 years (forest plots are shown in
High income 19 19.3 12.8–28.0 Supplementary Fig. 7–8). The pooled prevalence of mild-to-severe
Upper middle depression in children and adolescents was 7.1 % (95%CI, 5.5 %–9.0
24 18.8 12.5–27.3
income
P = 0.01
%; I2 = 73.06 %) and 27.4 % (95%CI, 21.1 %–34.7 %; I2 = 99.70 %)
Lower middle respectively. The pooled prevalence of major depression in children and
14 32.3 19.8–47.9
income
Low income 3 12.7 9.3–17.2
adolescents was 1.6 % (95%CI, 1.1 %–2.3 %; I2 = 79.54 %) and 5.5 %
(95%CI, 3.7 %–8.3 %; I2 = 98.47 %) respectively. The subgroup effects
were all statistically significant (P < 0.01). Due to insufficient data on
the prevalence of moderate-to-severe depression in children, a subgroup
Table 2
analysis of moderate-to-severe depression was not performed.
Prevalence estimates of moderate-to-severe depression across three income
groups.
Income group No. of Pooled 95%CI Subgroup 3.7. Sensitivity analysis and publication bias
studies prevalence (%) differences

High income 10 11.6 8.2–16.3 Post-hoc sensitivity analysis showed that after excluding Chinese
Upper middle studies, the pooled prevalence of mild-to-severe depression was 22.8 %
9 22.5 14.4–33.3
income P < 0.01
(95 % CI, 17.1 %–29.7 %), the pooled prevalence of moderate-to-severe
Lower middle
8 23.6 16.4–32.8 depression was 18.8 % (95 % CI, 14.3 %–24.3 %), and the pooled
income
prevalence of major depression was 4.0 % (95 % CI, 2.8 %–5.6 %),
similar to the main findings. Forest plots for post-hoc sensitivity analysis
are shown in Supplementary Fig. 9–11. Applying leave-one-out sensi­
Table 3 tivity analysis also did not significantly alter the pooled estimates of the
Prevalence estimates of major depression across three income groups. prevalence of mild-to-severe, moderate-to-severe, and major depression
Income group No. of Pooled 95%CI Subgroup (Supplementary Tables 7–9), further indicating the robustness of the
studies prevalence (%) differences findings.
High income 11 4.4 2.8–6.9 Begg’s tests were used to assess publication bias in mild-to-severe,
Upper middle
10 2.7 1.5–4.9 moderate-to-severe, and major depression prevalence. The results indi­
income P = 0.38
cated that there was no significant publication bias in the present meta-
Lower middle
income
6 4.5 2.4–8.3 analysis (P = 0.750, P = 0.527, P = 0.108, respectively). Funnel plots are
shown in Supplementary Fig. 12–14.

countries are shown in Table 1 (The forest plot is shown in Supple­
mentary Fig. 4). Among them, lower-middle-income countries have the
highest pooled prevalence, 32.3 % (95 % CI, 19.8 %–47.9 %); low-
income countries have the lowest pooled prevalence, 12.7 % (95 % CI,
9.3 %–17.2 %). The subgroup effect was statistically significant (P =
0.01).
Only one study reported a prevalence of moderate-to-severe
depression of 53.9 % (95 % CI, 48.8 %–58.9 %) in low-income coun­
tries. Prevalence estimates of moderate-to-severe depression in the other
three income groups are shown in Table 2 (The forest plot is shown in
Supplementary Fig. 5). Lower-middle-income countries have the highest
pooled prevalence, 23.6 % (95 % CI, 16.4 %–32.8 %); high-income
countries have the lowest pooled prevalence, 11.6 % (95 % CI, 8.2 %–
16.3 %). The subgroup effect was statistically significant (P < 0.01).
No studies reported major depression prevalence in low-income
countries. Prevalence estimates of major depression in the other three
income groups are shown in Table 3 (The forest plot is shown in Sup­
plementary Fig. 6). The pooled prevalence of the three ranged from 2.7
% (95 % CI, 1.5 %–4.9 %) to 4.5 % (95 % CI, 2.4 %–8.3 %), but there was
no significant subgroup difference (P = 0.38).
4. Discussion
This systematic review and meta-analysis provides comprehensive
quantitative estimates of varying levels of depression in children and
adolescents worldwide. To our knowledge, this is the most extensive
study of its kind to date. The findings indicate that depression is prev­
alent among children and adolescents worldwide, with prevalence es­
timates of mild-to-severe depression at 21.3 %, moderate-to-severe
depression at 18.9 %, and major depression at 3.7 %. There is high
heterogeneity among the included studies, and possible influencing
factors found through subgroup analysis and meta-regression analysis
include: measurement instrument and cut-off point, survey time,
respondent age, study country, etc. From 1989 to 2022, the prevalence
of mild-to-severe and moderate-to-severe depression showed a clear
increasing trend over time. The prevalence of depression among ado­
lescents aged 10–18 years was much higher than that among children
under 10 years old, about four times as high. There was a serious lack of
data on depression prevalence in low-income countries; among the other
three income levels, lower-middle-income countries had the highest
depression burden.
Like other systematic reviews of prevalence studies (Borges Miglia­
vaca et al., 2020), there was significant heterogeneity in the studies
included in this meta-analysis, which might be related to factors such as
the measurement instruments used and the study population itself

Table 4
Prevalence estimates of depression in children under 10 years and adolescents aged 10–18 years.
Age Mild-to-severe depression Major depression

No. of studies Pooled prevalence (%) 95%CI Subgroup differences No. of studies Pooled prevalence (%) 95%CI Subgroup differences

<10 years 3 7.1 5.5–9.0 2 1.6 1.1–2.3

P < 0.01 P < 0.01
10–18 years 43 27.4 21.1–34.7 15 5.5 3.7–8.3

560
B. Lu et al.
(Thapar et al., 2022). The 96 studies included in this review used nearly
30 self-report scales or structured interviews to assess depressive
symptoms. The diversity of depression measurement instruments is
partly related to the heterogeneity of depression itself. Depression has
no single definition, manifests itself more or less differently in in­
dividuals, and has varying patterns in different cultural settings and
social contexts (Herrman et al., 2022). There are more than two hundred
different ways to meet the DSM-5 diagnostic threshold for a major
depressive episode due to varying combinations of affective, cognitive,
and behavioral symptoms (Hawrilenko et al., 2021). Compared with the
narrower definition of “depression” in the DSM-5, the scale also focuses
on subthreshold depressive symptoms, and different scales have
different emphasis on affective, cognitive, and behavioral symptoms,
which results in there were only moderate correlations between the
scales (Fried, 2017). This means that a person’s level of “depression”
could vary greatly depending on the measurement instrument.
Our results suggest that depression is approximately four times more
common in adolescents than in children, consistent with other studies
(Wickersham et al., 2021; Wright et al., 2021). Previous studies have
shown that adolescence is a period of high incidence of depression and a
critical period for identification and intervention (Arias-de la Torre
et al., 2020; Hankin and Griffith, 2023; Venkatesan, 2023). Age-related
factors such as biological changes during adolescence and psychosocial
stress might explain this age dependence (Hawrilenko et al., 2021).
However, in addition to typical depressive behaviors, adolescents with
depression often exhibit irritability, aggression, avoidance and other
behaviors considered common in adolescence, which leads to the
neglect or denial of adolescent depression problems (Arias-de la Torre
et al., 2020; Edwards et al., 2022).
Depression has become increasingly common among children and
adolescents in recent years (Thapar et al., 2022). The annual cross-
sectional surveys in the United States found that depression preva­
lence among adolescents aged 12–17 increased from 8.7 % in 2005 to
12.7 % in 2015 (Weinberger et al., 2017). According to data from the
National Survey of Children’s Health, depression prevalence among
children and adolescents in the United States increased by 24 % from
2016 to 2019 (Lebrun-Harris et al., 2022). The COVID-19 pandemic has
further exacerbated the global mental health burden. A systematic re­
view found that approximately 25 % of adolescents globally had clini­
cally significant depressive symptoms during the epidemic, double the
number before the pandemic (Racine et al., 2021). In addition to the
impact of the epidemic, the rising prevalence of depression in children
and adolescents might also be related to factors such as increased aca­
demic pressure and Internet use (Dong et al., 2023; Fitzpatrick et al.,
2023).
This systematic review and meta-analysis found that there is a
serious lack of data on depression prevalence in children and adoles­
cents in low-income countries, and the prevalence in lower-middle-
income countries is higher than that in high-income countries. Previ­
ous research has shown that there is a huge gap in mental health services
in low- and middle-income countries, with up to 80–90 % of depression
patients not receiving diagnosis or treatment (Vigo et al., 2020).
Depression is a major risk factor for adolescents’ suicide (Hetrick et al.,
2021; Stallwood et al., 2021; Wright et al., 2021). According to the
World Health Organization, low- and middle-income countries account
for 77 % of global suicides (WHO, 2023). In the wake of the COVID-19
pandemic, the American Academy of Pediatrics, American Academy of
Child and Adolescent Psychiatry, and Children’s Hospital Association
declared a national state of emergency in child and adolescent mental
health (Tanne, 2022). In this context, the mental health of children and
adolescents in low- and middle-income countries where the depression
burden is higher and mental health services are scarcer should receive
greater attention.
Depression is a complex condition and everyone experiences
depression differently. Recognizing the complexity of depression and
moving beyond a one-size-fits-all approach is key to preventing and
561
Journal of Affective Disorders 354 (2024) 553–562
treating depression. In 2022, The Lancet published “Time for united
action on depression: a Lancet–World Psychiatric Association Commis­
sion” (Herrman et al., 2022), which called on governments, medical
service providers, researchers, depression patients and their families to
make coordinated efforts, adopt a strategy of joint action by the whole
society at multiple levels, improve understanding and attention to
depression, increase investment in social resources, create a good social
and family environment, and implement personalized and phased care
for depression patients to alleviate the global depression burden.
This study estimates the global prevalence of depression in children
and adolescents based on high-quality evidence and explores the tem­
poral and regional distribution of depression. In order to pool as ho­
mogeneous studies as possible, we graded depression with reference to
commonly used cutoffs for measurement instruments, although the
different levels of severity of depression have yet to be validly charac­
terized (Herrman et al., 2022). This study also has certain limitations.
First, this systematic review and meta-analysis only included English
articles. Second, due to the influence of measurement instruments, cut-
off points, survey time, respondent demographic characteristics and
other factors, there was significant heterogeneity across the studies
included in this meta-analysis. Although we attempted to improve
comparability through stratification, we still found considerable evi­
dence of heterogeneity. Third, except for a few studies focusing on major
depression, the studies included in this systematic review were all based
on self-report scales to assess depressive symptoms. As noted previously,
there is considerable variation across scales. Their validity is limited
compared with the gold-standard clinical diagnostic interview for major
depressive disorder. Given the heterogeneity among included studies
and the restricted validity of self-report data, our findings should be
interpreted as indicative only.
5. Conclusion
This systematic review and meta-analysis focuses on pooled preva­
lence estimates of depression or depressive symptoms in children and
adolescents worldwide. In this systematic review, about one in five
children and adolescents globally suffered from depression or had
depressive symptoms, and this proportion was increasing over time. Our
findings might help prompt policymakers to increase attention and re­
sources to depression in children and adolescents, especially those in
adolescence and those living in low- and middle-income countries.
Funding support
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
CRediT authorship contribution statement
Bingqing Lu: Writing – review & editing, Writing – original draft,
Visualization, Methodology, Data curation, Conceptualization. Lixia
Lin: Writing – review & editing, Visualization, Supervision, Methodol­
ogy, Conceptualization. Xiaojuan Su: Writing – review & editing,
Methodology, Data curation.
Declaration of competing interest
The authors declare that they have no conflict of interest.
Acknowledgements
None.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
B. Lu et al.
org/10.1016/j.jad.2024.03.074.
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