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Changes in the global burden of depression from 1990 to 2017: Findings from the Global Burden of Disease study
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Changes in the global burden of depression from 1990 to 2017: Findings from the Global Burden of Disease study Qingqing Liua,b,1, Hairong Hea,1, Jin Yanga,b, Xiaojie Fenga,b, Fanfan Zhaoa,b, Jun Lyua,b, a b
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Clinical Research Center, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, China
A R T I C LE I N FO
A B S T R A C T
Keywords: Depression The global burden of disease Dysthymia Major depressive disorder
Objective: Depression is the most common mental illness worldwide. It has become an important public health problem. This study aimed to determine the global burden of depression and how it has changed between 1990 and 2017. Methods: We used information on depression obtained by the Global Burden of Disease (GBD) study from 1990 to 2017. The age-standardized incidence rate (ASR) and estimated annual percentage change (EAPC) were used to assess the global burden of depression. Results: The number of incident cases of depression worldwide increased from 172 million in 1990 to 25,8 million in 2017, representing an increase of 49.86%. The ASR of depression varied widely between the 195 analyzed countries and regions in 2017, being highest in Lesotho (6.59 per 1000) and lowest in Myanmar (1.28 per 1000). The ASR increased the most between 1990 and 2017 in Belgium (EAPC = 0.88, 95% confidence interval [CI] = 0.78 to 0.97), and decreased the most in Cuba (EAPC = −1.26, 95% CI = −1.36 to −1.14). The ASR increased in regions with a high sociodemographic index, such as high-income North America (EAPC = 0.41, 95% CI = 0.31 to 0.51), and decreased significantly in South Asia (EAPC = −0.63, 95% CI = −0.85 to −0.41). The proportions of the population with major depressive disorder and dysthymia were essentially stable both globally and in various countries, with a much larger proportion having major depressive disorder. Conclusion: Depression remains a major public health issue, and governments should support the research necessary to develop better prevention and treatment interventions.
1. Introduction Depression is a common mental health disorder that can affect both the mental and physical health. The main symptoms of depression are a lack of interest in usual life activities, insomnia, inability to enjoy life, and even suicidal thoughts (Cui, 2015). Depression is nowadays a common chronic disease in most societies worldwide that can impair normal functioning, cause depressive thoughts, and adversely affect the quality of life. In addition, patients with major depressive disorder have increased risks of developing cardiovascular disease and receiving poor treatment, and increased morbidity and mortality (Luo et al., 2018; Seligman and Nemeroff, 2015). It is estimated that more than 300 million people in the world suffer from depression, which is listed by the World Health Organization (WHO) as the single largest factor contributing to global disability (Smith, 2014). One of the most-
worrying aspects is that adolescents with severe depression are 30 times more likely to commit suicide (Stringaris, 2017). However, while depression is now one of the most important global health problems, its complex pathogenesis remains poorly understood, although it is known that cultural, psychological, and biological factors contributed to depression (Gross, 2014; Menard et al., 2016). The Global Burden of Disease (GBD) study provides specific data on multiple diseases in 195 countries and regions around the world, including information about depression. The GBD database represents a wealth of information for understanding the incidence of depression worldwide, and it divides depression into two major categories: dysthymia and major depressive disorder. In this study we used the data on depression in the GBD database from 1990 to 2017 to analyze the temporal trends in the incidence of depression. Our findings will help to improve the understanding of the burden of depression worldwide and
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Corresponding author. Clinical Research Center, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, People's Republic of China. E-mail address: [email protected] (J. Lyu). 1 These authors contributed equally to this work. https://doi.org/10.1016/j.jpsychires.2019.08.002 Received 22 June 2019; Received in revised form 3 August 2019; Accepted 8 August 2019 0022-3956/ © 2019 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
Please cite this article as: Qingqing Liu, et al., Journal of Psychiatric Research, https://doi.org/10.1016/j.jpsychires.2019.08.002
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incident cases of depression worldwide increased from 172 million in 1990 to 25,8 milion in 2017, representing an increase of 49.86%. The increase was largest in Qatar (559.33%), followed by the United Arab Emirates (511.76%) and Equatorial Guinea (221.87%) (Fig. 1B). The number of incident cases of depression decreased from 1990 to 2017 in 18 countries, by the most in Latvia (−30.99%), followed by Bosnia and Herzegovina (−25.75%) and Georgia (−23.98%). The increase in ASR across the 195 countries and regions was largest in Belgium (EAPC = 0.88, 95% CI = 0.78 to 0.97), followed by Guyana (EAPC = 0.53, 95% CI = 0.42 to 0.64) and South Korea (EAPC = 0.52, 95% CI = 0.41 to 0.64) (Fig. 1C). The decrease in ASR was largest in Cuba (EAPC = −1.26, 95% CI = −1.36 to −1.14), followed by Denmark (EAPC = −1.21, 95% CI = −1.37 to −1.04) and Estonia (EAPC = −1.06, 95% CI = −1.18 to −0.94). Cluster analysis (Fig. S1) classified the ASR as (1) significantly increased in 29 countries, including Armenia, Belgium, and Iran; (2) slightly increased in 132 countries, including Afghanistan, Albania, and Australia; (3) remaining stable or slightly decreased in 25 countries, including Austria, Bahrain, and Bermuda; and (4) significant decreased in 9 countries, including Cuba, Bosnia and Herzegovina, and Denmark. The number of people with depression increased in all five SDI regions between 1990 and 2017 (Fig. 2). However, the ASR decreased in the high-middle-SDI, low-SDI, low-middle-SDI, and middle-SDI regions, only increasing in the high-SDI region (Table 1). The number of people with depression increased in all geographical regions (Fig. 3), by the most in Central sub-Saharan Africa (124.56%), followed by Western sub-Saharan Africa (124.42%) and Oceania (107.19%). The ASR increased significantly in high-income North America (EAPC = 0.41, 95% CI = 0.31 to 0.51) and decreased significantly in South Asia (EAPC = −0.63, 95% CI = −0.85 to–0.41) (Fig. 4, Table 1). Fig. 4 shows the proportions of cases of dysthymia and major depressive disorder worldwide in 1990 and 2017. The proportion of the population with the two types of depression remained essentially stable both globally and regionally, with a much larger proportion having major depressive disorder.
in developing effective prevention strategies. 2. Methods 2.1. Data source The data utilized in this study are available on the Global Health website (http://ghdx.healthdata.org). Each step used in this study to analyze the GBD database was consistent with the Guidelines for Accurate and Transparent Health Estimates Reporting, which has been described in detail previously (2016a; 2016b; 2016c; Stevens et al., 2016). The GBD database contains data on different diseases in 195 countries and regions, and we extracted data on depression from 1990 to 2017. In order to describe the prevalence of depression from multiple angles, we divided the world into five regions according to their sociodemographic index (SDI): low, low-middle, middle, high-middle, and high SDI. These 195 countries and regions were geographically divided into 21 areas, such as Andean Latin America, Central Europe, and Southeast Asia. This study used these data to describe the prevalence of dysthymia and major depressive disorder according to different SDI regions and geographical locations. In GBD, depression is divided into two categories: dysthymia and major depressive disorder. The study also described the prevalence of these two types of depression in different countries and regions, different SDI regions, and geographical locations. 2.2. Statistical analysis The age-standardized incidence rate (ASR) and estimated annual percentage change (EAPC) were used to quantify the incidence trends of depression (Hankey et al., 2000). The age-standardized morbidity is the morbidity after excluding the effects of age. The ASR of depression does not reflect the actual incidence of depression, but is only used to compare the incidence of depression in different countries, different regions, or different historical periods in the same region, so as to facilitate data comparisons. If the age structures of the populations in two regions are very different, comparing the incidence rates alone will not reveal whether a high incidence in a certain region is caused by the difference in the age compositions or other influencing factors. It is therefore necessary to standardize the incidence rate according to age. The method used to calculate ASR has been reported previously (Liu et al., 2019). EAPC is a summary and widely used measure of the ASR trend over a specific time interval. A regression line was fitted to the natural logarithm of the ASR values; that is, y = α + βx + ϵ, where y = ln (ASR) and x = calendar year. The EAPC was calculated as 100 × (exp (β) − 1), and its 95% confidence interval (CI) was obtained from a linear regression model (Liu et al., 2019). The ASR is considered to be (1) decreasing when the EAPC and the upper boundary of its 95% CI are both ≤0, (2) increasing when the EAPC and the lower boundary of its 95% CI are ≥0, and (3) stable in all other cases. In addition, the ASR values for the two types of depression were analyzed by hierarchical cluster analysis, and the countries and regions were divided into four states: significantly increased, slightly increased, remaining stable or slightly decreased, and significantly decreased. All statistical analyses in this study were performed using R software.
3.2. Global burden of major depressive disorder The majority (93.7%) of patients with depression in 2017 had major depressive disorder (Fig. 5). The ASR of major depressive disorder varied widely among the 195 countries and regions in 2017, being highest in Lesotho (6.41 per 1000), followed by Morocco (6.13 per 1000) and Greenland (6.01 per 1000) (Fig. S2), and lowest in Myanmar (1.06 per 1000), Indonesia (1.57 per 1000), and the Philippines (1.75 per 1000). The number of incident cases of major depressive disorder worldwide increased from 162 million in 1990 to 241 million in 2017, representing an increase of 49.29%. The increase was largest in Qatar (557.67%), followed by the United Arab Emirates (509.93%) and Equatorial Guinea (221.51%) (Fig. S3, Table S3). The number of incident cases decreased from 1990 to 2017 in 20 countries, by the most in Latvia (−31.49%), followed by Bosnia and Herzegovina (−26.65%) and Georgia (−23.69%). The increase in ASR across the 195 countries and regions was largest in Belgium (EAPC = 0.93, 95% CI = 0.83 to 1.02), followed by South Korea (EAPC = 0.57, 95% CI = 0.45 to 0.69) and Guyana (EAPC = 0.55, 95% CI = 0.44 to 0.66) (Fig. S4). The decrease in the ASR was largest in Cuba (EAPC = −1.31, 95% CI = −1.42 to −1.19), followed by Denmark (EAPC = −1.29, 95% CI = −1.47 to −1.11) and Estonia (EAPC = −1.12, 95% CI = −1.24 to −0.99). The number of cases of major depressive disorder in the five SDI regions increased between 1990 and 2017. However, the ASR decreased in the high-middle-SDI, low-SDI, low-middle-SDI, and middle-SDI regions, only increasing in the high-SDI region (Fig. 2, Table S1). The number of cases of major depressive disorder increased in all geographical regions (Fig. 3), by the most in Central sub-Saharan Africa (124.33%), followed by Western sub-Saharan Africa (124.11%) and
3. Results 3.1. Global burden of depression The ASR of depression in the 195 analyzed countries and regions varied widely in 2017 (Fig. 1A), being highest in Lesotho (6.59 per 1000), followed by Morocco (6.31 per 1000) and Greenland (6.26 per 1000), and lowest in Myanmar (1.28 per 1000), followed by Indonesia (1.79 per 1000) and the Philippines (1.97 per 1000). The number of 2
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Fig. 1. The global disease burden of depression for both sexes in 195 countries and territories. (A) The ASR of depression in 2017; (B) The relative change in incident cases of depression between 1990 and 2017; (C) The EAPC of depression ASR from 1990 to 2017. ASR, age-standardized rate; EAPC, estimated annual percentage change. 3
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Fig. 2. The depression cases caused by different types, by SDI regions, from 1990 to 2017. SDI, socio-demographic index.
Table 1 The incident cases and age-standardized incidence of depression in 1990 and 2017, and its temporal trends from 1990 to 2017. Characteristics
Global Sex Male Female Etiology Depressive disorders Major depressive disorder Dythymia Socio-demographic index High SDI High-middle SDI Low SDI Low-middle SDI Middle SDI Region Andean Latin America Australasia Caribbean Central Asia Central Europe Central Latin America Central Sub-Saharan Africa East Asia Eastern Europe Eastern Sub-Saharan Africa High-income Asia Pacific High-income North America North Africa and Middle East Oceania South Asia Southeast Asia Southern Latin America Southern Sub-Saharan Africa Tropical Latin America Western Europe Western Sub-Saharan Africa
1990
2017
1990–2017
Incident cases
ASR per 1000
Incident cases
ASR per 1000
EAPC
No. × 106 (95%UI)
No.(95%UI)
No. × 106 (95%UI)
No.(95%UI)
No.(95%UI)
172.27 (157.81–189.31)
3.43 (3.16–3.77)
258.16 (238.28–281.67)
3.25 (3–3.54)
−0.26 (−0.31 to −0.22)
65.1 (59.58–71.43) 107.16 (98.23–117.69)
2.6 (2.4–2.85) 4.25 (3.91–4.66)
99.87 (92.07–108.9) 158.29 (146.19–172.75)
2.54 (2.34–2.76) 3.95 (3.64–4.31)
−0.15 (−0.2 to −0.1) −0.33 (−0.38 to −0.29)
172.27 (157.81–189.31) 162.03 (147.45–178.81) 10.23 (8.97–11.61)
3.43 (3.16–3.77) 3.23 (2.96–3.55) 0.2 (0.18–0.23)
258.16 (238.28–281.67) 241.89 (222.03–265.57) 16.27 (14.24–18.42)
3.25 (3–3.54) 3.04 (2.8–3.34) 0.2 (0.18–0.23)
−0.26 (−0.31 to −0.22) 0.01 (−0.01 - 0.02) −0.28 (−0.33 to −0.23)
37.08 37.79 21.04 33.66 41.99
3.51 3.47 4.03 3.99 3.01
45.18 51.88 40.01 57.55 62.61
3.57 3.23 3.82 3.73 2.78
(3.3–3.89) (2.97–3.53) (3.5–4.18) (3.42–4.08) (2.56–3.02)
0.12 (0.1–0.15) −0.29 (−0.3 to −0.27) −0.32 (−0.44 to −0.2) −0.39 (−0.52 to −0.25) −0.36 (−0.4 to −0.33)
2.56 (2.34–2.79) 4.31 (3.93–4.77) 3.2 (2.93–3.49) 2.81 (2.59–3.05) 2.31 (2.13–2.51) 2.74 (2.52–3) 4.52 (4.13–4.98) 2.62 (2.41–2.85) 3.54 (3.2–3.94) 4.19 (3.84–4.59) 3.14 (2.9–3.42) 4.32 (3.98–4.7) 4.36 (3.98–4.81) 2.61 (2.39–2.88) 3.66 (3.36–4) 2 (1.84–2.19) 3.38 (3.08–3.73) 3.91 (3.6–4.28) 3.44 (3.18–3.75) 3.51 (3.23–3.84) 4.02 (3.68–4.4)
−0.18 (−0.2 to −0.15) −0.07 (−0.16 - 0.02) −0.5 (−0.54 to −0.46) −0.16 (−0.19 to −0.13) −0.45 (−0.49 to −0.41) 0 (−0.08 - 0.08) −0.12 (−0.14 to −0.11) −0.58 (−0.66 to −0.5) −0.43 (−0.53 to −0.33) −0.26 (−0.31 to −0.21) 0.38 (0.29–0.47) 0.41 (0.31–0.51) −0.07 (−0.1 to −0.03) −0.01 (−0.03 - 0.02) −0.63 (−0.85 to −0.41) −0.2 (−0.22 to −0.17) −0.17 (−0.2 to −0.14) −0.06 (−0.1 to −0.03) −0.47 (−0.95 - 0.01) −0.23 (−0.28 to −0.19) 0.11 (0.04–0.18)
(34.51–40.25) (34.58–41.53) (19.05–23.28) (30.64–37.11) (38.19–46.41)
0.84 (0.76–0.93) 0.94 (0.86–1.03) 1.18 (1.08–1.3) 1.75 (1.61–1.93) 3.45 (3.19–3.76) 3.66 (3.31–4.04) 1.92 (1.72–2.14) 37.65 (34.37–41.59) 9.6 (8.67–10.71) 5.91 (5.32–6.57) 5.4 (4.99–5.88) 11.91 (10.93–13.1) 12.54 (11.32–13.93) 0.14 (0.13–0.16) 36.1 (32.87–40.03) 8.6 (7.78–9.53) 1.71 (1.57–1.87) 1.71 (1.55–1.9) 5.29 (4.81–5.86) 16.34 (15.28–17.6) 5.62 (5.11–6.22)
(3.26–3.81) (3.18–3.79) (3.68–4.44) (3.65–4.38) (2.76–3.3)
2.62 (2.41–2.89) 4.38 (4–4.79) 3.58 (3.29–3.9) 2.91 (2.68–3.18) 2.54 (2.34–2.77) 2.69 (2.46–2.96) 4.64 (4.21–5.11) 3.08 (2.83–3.38) 3.78 (3.42–4.21) 4.43 (4.03–4.87) 2.84 (2.62–3.09) 4 (3.66–4.41) 4.4 (4–4.86) 2.6 (2.37–2.87) 4.05 (3.7–4.47) 2.09 (1.9–2.29) 3.48 (3.21–3.81) 3.97 (3.63–4.36) 3.85 (3.53–4.22) 3.78 (3.52–4.08) 4.05 (3.69–4.45)
(42.01–48.88) (47.53–56.74) (36.52–44.16) (52.85–63.2) (57.55–68.3)
1.53 (1.4–1.67) 1.27 (1.17–1.4) 1.57 (1.43–1.71) 2.47 (2.27–2.68) 3.39 (3.13–3.67) 7.04 (6.46–7.7) 4.3 (3.88–4.8) 48.27 (44.11–52.77) 9.21 (8.29–10.27) 12.06 (10.91–13.35) 6.73 (6.25–7.29) 16.16 (14.99–17.48) 25.74 (23.36–28.58) 0.29 (0.26–0.33) 61.19 (56.13–67.06) 13.58 (12.43–14.87) 2.34 (2.13–2.57) 2.83 (2.59–3.12) 8.03 (7.42–8.72) 17.53 (16.19–19) 12.62 (11.45–13.97)
4
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Fig. 3. The incident cases of depression at a regional level. The left column in each group is case data in 1990 and the right column in 2017.
3.3. Global burden of dysthymia
Oceania (106.85%). The ASR increased significantly in high-income North America (EAPC = 0.46, 95% CI = 0.35 to 0.56) and decreased significantly in South Asia (EAPC = −0.67, 95% CI = −0.90 to −0.43) (Fig. 4, Table 1).
Only 6.3% of the patients with depression in 2017 had dysthymia in 2017 (Fig. 5). The ASR of dysthymia varied widely among the 195 countries and regions in 2017, being highest in the United States (0.26 per 1000), followed by Canada (0.25 per 1000) and Greenland (0.25
Fig. 4. The EAPC of depression ASR from 1990 to 2017, both sexes, by region, and by types. 5
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Fig. 5. Contribution of major depressive disorder and dysthymia to absolute depression incident cases, both sexes, globally and by region, in 1990 and 2017.
treatment (Cerutti et al., 2016). People diagnosed with HIV/AIDS often face social stigma and restrictions in employment and marriage, which in some cases leads to divorce and family exclusion (Ironson et al., 2017). People with HIV may experience depression for many reasons, such as over concern about disease progression, pain, and death (Junqueira et al., 2008). These characteristics of the situation in Lesotho mean that preventing AIDS could be a key measure to control depression. The ASR increased the most in Belgium, followed by Guyana and South Korea. More research is needed to understand the causes of increased ASR in depression in these countries. The country with the largest reductions in ASR was Cuba, followed by Denmark and Estonia. The ASR increased significantly in the high-SDI region and high-income North America (EAPC = 0.41, 95% CI = 0.31 to 0.51). The rapid increases in the ASR of depression in these regions could be due to them having high levels of economic development, education, and social pressure. Studies have found that education can affect cognitive ability. It can affect depression in individuals and even in spouses (Lee, 2011). Social stress is also a recognized risk factor for depression (Smith, 2014). Our findings show that the proportions of both types of depression were essentially stable both globally and regionally, with a large proportion of patients having major depressive disorder. As the most common cause of disability affecting nearly 16% of the global population (Kessler et al., 2003), major depressive disorder is attracting increasing attention. A WHO report predicted that major depressive disorder will become the leading cause of disability in the world by 2030 (Yang et al., 2015), and stated that controlling major depressive disorder is the best way to address depression. Regarding the ASR of dysthymia, although this has decreased the most in the United States, that country still had the highest ASR in 2017. This shows that the United States should pay more attention to this problem and continue to take measures aimed at controlling dysthymia. The ASR of dysthymia decreased the most in the high-SDI region and high-income North America, while the ASR of major depressive disorder increased the most in these areas. This might be because some of the patients with dysthymia in these areas progressed to major depressive disorder. This study identified that there are especially high rates of depression in some countries and regions, indicating the importance of identifying the underlying reasons. Although the pathogenesis of depression is unknown, some studies have identified risk factors for depression. Depressed people have a genetic predisposition, with the risk of
per 1000) (Fig. S5), and lowest in Colombia (0.13 per 1000), followed by Romania (0.15 per 1000) and Panama (0.15 per 1000). The number of incident cases of dysthymia worldwide increased from 10 million in 1990 to 16 million in 2017, representing an increase of 58.98%. The increase was largest in Qatar (601.91%), followed by the United Arab Emirates (547.94%) and Bahrain (250.72%) (Fig. S6, Table S5). The number of incident cases decreased from 1990 to 2017 in 11 countries, by the most in Georgia (−27.65%), followed by Latvia (−22.52%) and Lithuania (−15.44%). The increase in ASR across the 195 countries and regions was largest in Iran (EAPC = 0.12, 95% CI = 0.06 to 0.21), followed by India (EAPC = 0.11, 95% CI = 0.09 to 0.13) and Portugal (EAPC = 0.11, 95% CI = 0.05 to 0.16) (Fig. S7). The decrease in ASR was largest in the United States (EAPC = −0.33, 95% CI = −0.43 to −0.24), followed by Colombia (EAPC = −0.21, 95% CI = −0.25 to–0.16) and Singapore (EAPC = −0.21, 95% CI = −0.31 to −0.09). The number of dysthymia cases in the five SDI regions increased between 1990 and 2017. However, the ASR only increased in the highmiddle-SDI, low-SDI, and low-middle-SDI regions, and decreased in the high-SDI and middle-SDI regions (Fig. 2, Table S1). The number of dysthymia cases increased in all geographical regions (Fig. 3), by the most in Western sub-Saharan Africa (130.23%), followed by Central sub-Saharan Africa (130.04%) and Eastern sub-Saharan Africa (117.02%). The ASR increased significantly in South Asia (EAPC = 0.09, 95% CI = 0.07 to 0.11) and decreased significantly in high-income North America (EAPC = −0.31, 95% CI = −0.39 to −0.22) (Fig. 4, Table 1).
4. Discussion Depression is a major public health problem and a major cause of disability (Ferrari et al., 2013). This study used data published in the GBD database to analyze the trends in depression from 1990 to 2017 and the global burden of depression. The results of this study can be used by governments in all regions to develop appropriate preventive measures for depression. This study found that the number of incident cases of depression worldwide increased by 49.86% from 1990 to 2017. The ASR was highest in Lesotho, which is a poor landlocked country surrounded by South Africa that has the third highest rate of HIV infection in the world, the highest rate of HIV transmission among the high-prevalence countries of southern Africa, and the lowest coverage of antiretroviral 6
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depression being significantly higher in relatives of depressed people—especially their first-degree relatives—than in the general population (Mullins and Lewis, 2017). Research has shown that age and gender are also linked to depression, with women more likely to suffer from depression than men, and older people more likely to suffer from depression as a result of more underlying illnesses (Faravelli et al., 2013; Zhao et al., 2012). In addition to genetic and psychological factors, studies have found that unhealthy lifestyles such as smoking and alcohol consumption increase the risk of depression (Gravely-Witte et al., 2009; Pavkovic et al., 2018). In addition, insomnia reportedly increases the risks of depression and anxiety (Li et al., 2016). Numerous studies have shown that certain diseases are related to the occurrence of depression. Depression is one of the most common neuropsychiatric consequences of stroke, affecting about one-third of stroke patients (Hackett et al., 2005). The prevalence of depressive symptoms in cancer patients exceeds that in the general population, and depression is associated with a poor prognosis in cancer patients (Sotelo et al., 2014). It has been found that children and adolescents with enterovirus infection are susceptible to secondary depression (Liao et al., 2017). The risk of depression is also higher in AIDS patients than in the general population (Elbadawi and Mirghani, 2017). The governments of countries with high rates of depression need to focus on supporting relevant research to identify the underlying causes and take measures to actively control the occurrence of depression. Healthy lifestyles such as increasing the amount of physical exercise and giving up smoking and drinking should be advocated. Patients with stroke, cancer, AIDS, and other diseases should be followed up and provided with appropriate medications to prevent the occurrence of depression. Medication and psychological interventions should be applied to people who are already suffering from depression in order to prevent suicidal behavior. This study has performed the most comprehensive assessment yet of the burden of depression. However, it was also subject to some limitations. Firstly, the analyzed data were obtained from the GBD database, in which depressive disorder is classified into major depressive disorder and dysthymia, and so we were only able to analyze the global burden of depression according to this classification method without further subdivision. Secondly, only the global disease burden of depression was analyzed, and the risk factors of depression in different countries and regions were not addressed. Future studies are needed to focus on this issue in order to guide the development and implementation of specific policies for controlling depression in different countries and regions.
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Behav. Med. 32 (5), 478–490. Gross, M., 2014. Silver linings for patients with depression? Curr. Biol. : CB 24 (18), R851–R854. Hackett, M.L., Yapa, C., Parag, V., Anderson, C.S., 2005. Frequency of depression after stroke: a systematic review of observational studies. Stroke 36 (6), 1330–1340. Hankey, B.F., Ries, L.A., Kosary, C.L., Feuer, E.J., Merrill, R.M., Clegg, L.X., Edwards, B.K., 2000. Partitioning linear trends in age-adjusted rates. Cancer causes & control : CCC (Cancer Causes Control) 11 (1), 31–35. Ironson, G., Henry, S.M., Gonzalez, B.D., 2017. Impact of stressful death or divorce in people with HIV: a prospective examination and the buffering effects of religious coping and social support. J. Health Psychol. 1359105317726151. Junqueira, P., Bellucci, S., Rossini, S., Reimao, R., 2008. Women living with HIV/AIDS: sleep impairment, anxiety and depression symptoms. Arquivos de neuro-psiquiatria 66 (4), 817–820. Kessler, R.C., Berglund, P., Demler, O., Jin, R., Koretz, D., Merikangas, K.R., Rush, A.J., Walters, E.E., Wang, P.S., 2003. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). Jama 289 (23), 3095–3105. Lee, J., 2011. Pathways from education to depression. J. Cross Cult. Gerontol. 26 (2), 121–135. Li, L., Wu, C., Gan, Y., Qu, X., Lu, Z., 2016. Insomnia and the risk of depression: a metaanalysis of prospective cohort studies. BMC Psychiatry 16 (1), 375. Liao, Y.T., Hsieh, M.H., Yang, Y.H., Wang, Y.C., Tsai, C.S., Chen, V.C., Gossop, M., 2017. Association between depression and enterovirus infection: a nationwide populationbased cohort study. Medicine 96 (5), e5983. Liu, Z., Jiang, Y., Yuan, H., Fang, Q., Cai, N., Suo, C., Jin, L., Zhang, T., Chen, X., 2019. The trends in incidence of primary liver cancer caused by specific etiologies: results from the Global Burden of Disease Study 2016 and implications for liver cancer prevention. J. Hepatol. 70 (4), 674–683. Luo, Y., Zhang, S., Zheng, R., Xu, L., Wu, J., 2018. Effects of depression on heart rate variability in elderly patients with stable coronary artery disease. J. Evid. Based Med. 11 (4), 242–245. Menard, C., Hodes, G.E., Russo, S.J., 2016. Pathogenesis of depression: insights from human and rodent studies. Neuroscience 321, 138–162. Mullins, N., Lewis, C.M., 2017. Genetics of depression: progress at last. Curr. Psychiatr. Rep. 19 (8), 43. Pavkovic, B., Zaric, M., Markovic, M., Klacar, M., Huljic, A., Caricic, A., 2018. Double screening for dual disorder, alcoholism and depression. Psychiatry Res. 270, 483–489. Seligman, F., Nemeroff, C.B., 2015. The interface of depression and cardiovascular disease: therapeutic implications. Ann. N. Y. Acad. Sci. 1345, 25–35. Smith, K., 2014. Mental health: a world of depression. Nature 515 (7526), 181. Sotelo, J.L., Musselman, D., Nemeroff, C., 2014. The biology of depression in cancer and the relationship between depression and cancer progression. Int. Rev. Psychiatry 26 (1), 16–30. Stevens, G.A., Alkema, L., Black, R.E., Boerma, J.T., Collins, G.S., Ezzati, M., Grove, J.T., Hogan, D.R., Hogan, M.C., Horton, R., Lawn, J.E., Marusic, A., Mathers, C.D., Murray, C.J., Rudan, I., Salomon, J.A., Simpson, P.J., Vos, T., Welch, V., 2016. Guidelines for accurate and transparent health Estimates reporting: the GATHER statement. Lancet (London, England) 388 (10062), e19–e23. Stringaris, A., 2017. Editorial: what is depression? J. Child Psychol. Psychiatry Allied Discip. 58 (12), 1287–1289. Yang, L., Zhao, Y., Wang, Y., Liu, L., Zhang, X., Li, B., Cui, R., 2015. The effects of psychological stress on depression. Curr. Neuropharmacol. 13 (4), 494–504. Zhao, K.X., Huang, C.Q., Xiao, Q., Gao, Y., Liu, Q.X., Wang, Z.R., Li, Y.H., Xie, Y.Z., 2012. Age and risk for depression among the elderly: a meta-analysis of the published literature. CNS Spectr. 17 (3), 142–154.
5. Conclusion Depression affects the mental and physical health of patients and, as the most common mental illness, has become an important public health problem. The findings of this study on the global burden of depression from 1990 to 2017 will help governments around the world to understand their own burdens of depression, and to formulate and implement measures for the prevention and early treatment of depression. Conflicts of interest The author reports no conflicts of interest in this work. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Appendix A. Supplementary data Supplementary data to this article can be found online at https:// 7
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Journal of Psychiatric Research journal homepage: www.elsevier.com/locate/jpsychires
Changes in the global burden of depression from 1990 to 2017: Findings from the Global Burden of Disease study Qingqing Liua,b,1, Hairong Hea,1, Jin Yanga,b, Xiaojie Fenga,b, Fanfan Zhaoa,b, Jun Lyua,b, a b
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Clinical Research Center, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, China
A R T I C LE I N FO
A B S T R A C T
Keywords: Depression The global burden of disease Dysthymia Major depressive disorder
Objective: Depression is the most common mental illness worldwide. It has become an important public health problem. This study aimed to determine the global burden of depression and how it has changed between 1990 and 2017. Methods: We used information on depression obtained by the Global Burden of Disease (GBD) study from 1990 to 2017. The age-standardized incidence rate (ASR) and estimated annual percentage change (EAPC) were used to assess the global burden of depression. Results: The number of incident cases of depression worldwide increased from 172 million in 1990 to 25,8 million in 2017, representing an increase of 49.86%. The ASR of depression varied widely between the 195 analyzed countries and regions in 2017, being highest in Lesotho (6.59 per 1000) and lowest in Myanmar (1.28 per 1000). The ASR increased the most between 1990 and 2017 in Belgium (EAPC = 0.88, 95% confidence interval [CI] = 0.78 to 0.97), and decreased the most in Cuba (EAPC = −1.26, 95% CI = −1.36 to −1.14). The ASR increased in regions with a high sociodemographic index, such as high-income North America (EAPC = 0.41, 95% CI = 0.31 to 0.51), and decreased significantly in South Asia (EAPC = −0.63, 95% CI = −0.85 to −0.41). The proportions of the population with major depressive disorder and dysthymia were essentially stable both globally and in various countries, with a much larger proportion having major depressive disorder. Conclusion: Depression remains a major public health issue, and governments should support the research necessary to develop better prevention and treatment interventions.
1. Introduction Depression is a common mental health disorder that can affect both the mental and physical health. The main symptoms of depression are a lack of interest in usual life activities, insomnia, inability to enjoy life, and even suicidal thoughts (Cui, 2015). Depression is nowadays a common chronic disease in most societies worldwide that can impair normal functioning, cause depressive thoughts, and adversely affect the quality of life. In addition, patients with major depressive disorder have increased risks of developing cardiovascular disease and receiving poor treatment, and increased morbidity and mortality (Luo et al., 2018; Seligman and Nemeroff, 2015). It is estimated that more than 300 million people in the world suffer from depression, which is listed by the World Health Organization (WHO) as the single largest factor contributing to global disability (Smith, 2014). One of the most-
worrying aspects is that adolescents with severe depression are 30 times more likely to commit suicide (Stringaris, 2017). However, while depression is now one of the most important global health problems, its complex pathogenesis remains poorly understood, although it is known that cultural, psychological, and biological factors contributed to depression (Gross, 2014; Menard et al., 2016). The Global Burden of Disease (GBD) study provides specific data on multiple diseases in 195 countries and regions around the world, including information about depression. The GBD database represents a wealth of information for understanding the incidence of depression worldwide, and it divides depression into two major categories: dysthymia and major depressive disorder. In this study we used the data on depression in the GBD database from 1990 to 2017 to analyze the temporal trends in the incidence of depression. Our findings will help to improve the understanding of the burden of depression worldwide and
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Corresponding author. Clinical Research Center, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, People's Republic of China. E-mail address: [email protected] (J. Lyu). 1 These authors contributed equally to this work. https://doi.org/10.1016/j.jpsychires.2019.08.002 Received 22 June 2019; Received in revised form 3 August 2019; Accepted 8 August 2019 0022-3956/ © 2019 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
Please cite this article as: Qingqing Liu, et al., Journal of Psychiatric Research, https://doi.org/10.1016/j.jpsychires.2019.08.002
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incident cases of depression worldwide increased from 172 million in 1990 to 25,8 milion in 2017, representing an increase of 49.86%. The increase was largest in Qatar (559.33%), followed by the United Arab Emirates (511.76%) and Equatorial Guinea (221.87%) (Fig. 1B). The number of incident cases of depression decreased from 1990 to 2017 in 18 countries, by the most in Latvia (−30.99%), followed by Bosnia and Herzegovina (−25.75%) and Georgia (−23.98%). The increase in ASR across the 195 countries and regions was largest in Belgium (EAPC = 0.88, 95% CI = 0.78 to 0.97), followed by Guyana (EAPC = 0.53, 95% CI = 0.42 to 0.64) and South Korea (EAPC = 0.52, 95% CI = 0.41 to 0.64) (Fig. 1C). The decrease in ASR was largest in Cuba (EAPC = −1.26, 95% CI = −1.36 to −1.14), followed by Denmark (EAPC = −1.21, 95% CI = −1.37 to −1.04) and Estonia (EAPC = −1.06, 95% CI = −1.18 to −0.94). Cluster analysis (Fig. S1) classified the ASR as (1) significantly increased in 29 countries, including Armenia, Belgium, and Iran; (2) slightly increased in 132 countries, including Afghanistan, Albania, and Australia; (3) remaining stable or slightly decreased in 25 countries, including Austria, Bahrain, and Bermuda; and (4) significant decreased in 9 countries, including Cuba, Bosnia and Herzegovina, and Denmark. The number of people with depression increased in all five SDI regions between 1990 and 2017 (Fig. 2). However, the ASR decreased in the high-middle-SDI, low-SDI, low-middle-SDI, and middle-SDI regions, only increasing in the high-SDI region (Table 1). The number of people with depression increased in all geographical regions (Fig. 3), by the most in Central sub-Saharan Africa (124.56%), followed by Western sub-Saharan Africa (124.42%) and Oceania (107.19%). The ASR increased significantly in high-income North America (EAPC = 0.41, 95% CI = 0.31 to 0.51) and decreased significantly in South Asia (EAPC = −0.63, 95% CI = −0.85 to–0.41) (Fig. 4, Table 1). Fig. 4 shows the proportions of cases of dysthymia and major depressive disorder worldwide in 1990 and 2017. The proportion of the population with the two types of depression remained essentially stable both globally and regionally, with a much larger proportion having major depressive disorder.
in developing effective prevention strategies. 2. Methods 2.1. Data source The data utilized in this study are available on the Global Health website (http://ghdx.healthdata.org). Each step used in this study to analyze the GBD database was consistent with the Guidelines for Accurate and Transparent Health Estimates Reporting, which has been described in detail previously (2016a; 2016b; 2016c; Stevens et al., 2016). The GBD database contains data on different diseases in 195 countries and regions, and we extracted data on depression from 1990 to 2017. In order to describe the prevalence of depression from multiple angles, we divided the world into five regions according to their sociodemographic index (SDI): low, low-middle, middle, high-middle, and high SDI. These 195 countries and regions were geographically divided into 21 areas, such as Andean Latin America, Central Europe, and Southeast Asia. This study used these data to describe the prevalence of dysthymia and major depressive disorder according to different SDI regions and geographical locations. In GBD, depression is divided into two categories: dysthymia and major depressive disorder. The study also described the prevalence of these two types of depression in different countries and regions, different SDI regions, and geographical locations. 2.2. Statistical analysis The age-standardized incidence rate (ASR) and estimated annual percentage change (EAPC) were used to quantify the incidence trends of depression (Hankey et al., 2000). The age-standardized morbidity is the morbidity after excluding the effects of age. The ASR of depression does not reflect the actual incidence of depression, but is only used to compare the incidence of depression in different countries, different regions, or different historical periods in the same region, so as to facilitate data comparisons. If the age structures of the populations in two regions are very different, comparing the incidence rates alone will not reveal whether a high incidence in a certain region is caused by the difference in the age compositions or other influencing factors. It is therefore necessary to standardize the incidence rate according to age. The method used to calculate ASR has been reported previously (Liu et al., 2019). EAPC is a summary and widely used measure of the ASR trend over a specific time interval. A regression line was fitted to the natural logarithm of the ASR values; that is, y = α + βx + ϵ, where y = ln (ASR) and x = calendar year. The EAPC was calculated as 100 × (exp (β) − 1), and its 95% confidence interval (CI) was obtained from a linear regression model (Liu et al., 2019). The ASR is considered to be (1) decreasing when the EAPC and the upper boundary of its 95% CI are both ≤0, (2) increasing when the EAPC and the lower boundary of its 95% CI are ≥0, and (3) stable in all other cases. In addition, the ASR values for the two types of depression were analyzed by hierarchical cluster analysis, and the countries and regions were divided into four states: significantly increased, slightly increased, remaining stable or slightly decreased, and significantly decreased. All statistical analyses in this study were performed using R software.
3.2. Global burden of major depressive disorder The majority (93.7%) of patients with depression in 2017 had major depressive disorder (Fig. 5). The ASR of major depressive disorder varied widely among the 195 countries and regions in 2017, being highest in Lesotho (6.41 per 1000), followed by Morocco (6.13 per 1000) and Greenland (6.01 per 1000) (Fig. S2), and lowest in Myanmar (1.06 per 1000), Indonesia (1.57 per 1000), and the Philippines (1.75 per 1000). The number of incident cases of major depressive disorder worldwide increased from 162 million in 1990 to 241 million in 2017, representing an increase of 49.29%. The increase was largest in Qatar (557.67%), followed by the United Arab Emirates (509.93%) and Equatorial Guinea (221.51%) (Fig. S3, Table S3). The number of incident cases decreased from 1990 to 2017 in 20 countries, by the most in Latvia (−31.49%), followed by Bosnia and Herzegovina (−26.65%) and Georgia (−23.69%). The increase in ASR across the 195 countries and regions was largest in Belgium (EAPC = 0.93, 95% CI = 0.83 to 1.02), followed by South Korea (EAPC = 0.57, 95% CI = 0.45 to 0.69) and Guyana (EAPC = 0.55, 95% CI = 0.44 to 0.66) (Fig. S4). The decrease in the ASR was largest in Cuba (EAPC = −1.31, 95% CI = −1.42 to −1.19), followed by Denmark (EAPC = −1.29, 95% CI = −1.47 to −1.11) and Estonia (EAPC = −1.12, 95% CI = −1.24 to −0.99). The number of cases of major depressive disorder in the five SDI regions increased between 1990 and 2017. However, the ASR decreased in the high-middle-SDI, low-SDI, low-middle-SDI, and middle-SDI regions, only increasing in the high-SDI region (Fig. 2, Table S1). The number of cases of major depressive disorder increased in all geographical regions (Fig. 3), by the most in Central sub-Saharan Africa (124.33%), followed by Western sub-Saharan Africa (124.11%) and
3. Results 3.1. Global burden of depression The ASR of depression in the 195 analyzed countries and regions varied widely in 2017 (Fig. 1A), being highest in Lesotho (6.59 per 1000), followed by Morocco (6.31 per 1000) and Greenland (6.26 per 1000), and lowest in Myanmar (1.28 per 1000), followed by Indonesia (1.79 per 1000) and the Philippines (1.97 per 1000). The number of 2
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Fig. 1. The global disease burden of depression for both sexes in 195 countries and territories. (A) The ASR of depression in 2017; (B) The relative change in incident cases of depression between 1990 and 2017; (C) The EAPC of depression ASR from 1990 to 2017. ASR, age-standardized rate; EAPC, estimated annual percentage change. 3
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Fig. 2. The depression cases caused by different types, by SDI regions, from 1990 to 2017. SDI, socio-demographic index.
Table 1 The incident cases and age-standardized incidence of depression in 1990 and 2017, and its temporal trends from 1990 to 2017. Characteristics
Global Sex Male Female Etiology Depressive disorders Major depressive disorder Dythymia Socio-demographic index High SDI High-middle SDI Low SDI Low-middle SDI Middle SDI Region Andean Latin America Australasia Caribbean Central Asia Central Europe Central Latin America Central Sub-Saharan Africa East Asia Eastern Europe Eastern Sub-Saharan Africa High-income Asia Pacific High-income North America North Africa and Middle East Oceania South Asia Southeast Asia Southern Latin America Southern Sub-Saharan Africa Tropical Latin America Western Europe Western Sub-Saharan Africa
1990
2017
1990–2017
Incident cases
ASR per 1000
Incident cases
ASR per 1000
EAPC
No. × 106 (95%UI)
No.(95%UI)
No. × 106 (95%UI)
No.(95%UI)
No.(95%UI)
172.27 (157.81–189.31)
3.43 (3.16–3.77)
258.16 (238.28–281.67)
3.25 (3–3.54)
−0.26 (−0.31 to −0.22)
65.1 (59.58–71.43) 107.16 (98.23–117.69)
2.6 (2.4–2.85) 4.25 (3.91–4.66)
99.87 (92.07–108.9) 158.29 (146.19–172.75)
2.54 (2.34–2.76) 3.95 (3.64–4.31)
−0.15 (−0.2 to −0.1) −0.33 (−0.38 to −0.29)
172.27 (157.81–189.31) 162.03 (147.45–178.81) 10.23 (8.97–11.61)
3.43 (3.16–3.77) 3.23 (2.96–3.55) 0.2 (0.18–0.23)
258.16 (238.28–281.67) 241.89 (222.03–265.57) 16.27 (14.24–18.42)
3.25 (3–3.54) 3.04 (2.8–3.34) 0.2 (0.18–0.23)
−0.26 (−0.31 to −0.22) 0.01 (−0.01 - 0.02) −0.28 (−0.33 to −0.23)
37.08 37.79 21.04 33.66 41.99
3.51 3.47 4.03 3.99 3.01
45.18 51.88 40.01 57.55 62.61
3.57 3.23 3.82 3.73 2.78
(3.3–3.89) (2.97–3.53) (3.5–4.18) (3.42–4.08) (2.56–3.02)
0.12 (0.1–0.15) −0.29 (−0.3 to −0.27) −0.32 (−0.44 to −0.2) −0.39 (−0.52 to −0.25) −0.36 (−0.4 to −0.33)
2.56 (2.34–2.79) 4.31 (3.93–4.77) 3.2 (2.93–3.49) 2.81 (2.59–3.05) 2.31 (2.13–2.51) 2.74 (2.52–3) 4.52 (4.13–4.98) 2.62 (2.41–2.85) 3.54 (3.2–3.94) 4.19 (3.84–4.59) 3.14 (2.9–3.42) 4.32 (3.98–4.7) 4.36 (3.98–4.81) 2.61 (2.39–2.88) 3.66 (3.36–4) 2 (1.84–2.19) 3.38 (3.08–3.73) 3.91 (3.6–4.28) 3.44 (3.18–3.75) 3.51 (3.23–3.84) 4.02 (3.68–4.4)
−0.18 (−0.2 to −0.15) −0.07 (−0.16 - 0.02) −0.5 (−0.54 to −0.46) −0.16 (−0.19 to −0.13) −0.45 (−0.49 to −0.41) 0 (−0.08 - 0.08) −0.12 (−0.14 to −0.11) −0.58 (−0.66 to −0.5) −0.43 (−0.53 to −0.33) −0.26 (−0.31 to −0.21) 0.38 (0.29–0.47) 0.41 (0.31–0.51) −0.07 (−0.1 to −0.03) −0.01 (−0.03 - 0.02) −0.63 (−0.85 to −0.41) −0.2 (−0.22 to −0.17) −0.17 (−0.2 to −0.14) −0.06 (−0.1 to −0.03) −0.47 (−0.95 - 0.01) −0.23 (−0.28 to −0.19) 0.11 (0.04–0.18)
(34.51–40.25) (34.58–41.53) (19.05–23.28) (30.64–37.11) (38.19–46.41)
0.84 (0.76–0.93) 0.94 (0.86–1.03) 1.18 (1.08–1.3) 1.75 (1.61–1.93) 3.45 (3.19–3.76) 3.66 (3.31–4.04) 1.92 (1.72–2.14) 37.65 (34.37–41.59) 9.6 (8.67–10.71) 5.91 (5.32–6.57) 5.4 (4.99–5.88) 11.91 (10.93–13.1) 12.54 (11.32–13.93) 0.14 (0.13–0.16) 36.1 (32.87–40.03) 8.6 (7.78–9.53) 1.71 (1.57–1.87) 1.71 (1.55–1.9) 5.29 (4.81–5.86) 16.34 (15.28–17.6) 5.62 (5.11–6.22)
(3.26–3.81) (3.18–3.79) (3.68–4.44) (3.65–4.38) (2.76–3.3)
2.62 (2.41–2.89) 4.38 (4–4.79) 3.58 (3.29–3.9) 2.91 (2.68–3.18) 2.54 (2.34–2.77) 2.69 (2.46–2.96) 4.64 (4.21–5.11) 3.08 (2.83–3.38) 3.78 (3.42–4.21) 4.43 (4.03–4.87) 2.84 (2.62–3.09) 4 (3.66–4.41) 4.4 (4–4.86) 2.6 (2.37–2.87) 4.05 (3.7–4.47) 2.09 (1.9–2.29) 3.48 (3.21–3.81) 3.97 (3.63–4.36) 3.85 (3.53–4.22) 3.78 (3.52–4.08) 4.05 (3.69–4.45)
(42.01–48.88) (47.53–56.74) (36.52–44.16) (52.85–63.2) (57.55–68.3)
1.53 (1.4–1.67) 1.27 (1.17–1.4) 1.57 (1.43–1.71) 2.47 (2.27–2.68) 3.39 (3.13–3.67) 7.04 (6.46–7.7) 4.3 (3.88–4.8) 48.27 (44.11–52.77) 9.21 (8.29–10.27) 12.06 (10.91–13.35) 6.73 (6.25–7.29) 16.16 (14.99–17.48) 25.74 (23.36–28.58) 0.29 (0.26–0.33) 61.19 (56.13–67.06) 13.58 (12.43–14.87) 2.34 (2.13–2.57) 2.83 (2.59–3.12) 8.03 (7.42–8.72) 17.53 (16.19–19) 12.62 (11.45–13.97)
4
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Fig. 3. The incident cases of depression at a regional level. The left column in each group is case data in 1990 and the right column in 2017.
3.3. Global burden of dysthymia
Oceania (106.85%). The ASR increased significantly in high-income North America (EAPC = 0.46, 95% CI = 0.35 to 0.56) and decreased significantly in South Asia (EAPC = −0.67, 95% CI = −0.90 to −0.43) (Fig. 4, Table 1).
Only 6.3% of the patients with depression in 2017 had dysthymia in 2017 (Fig. 5). The ASR of dysthymia varied widely among the 195 countries and regions in 2017, being highest in the United States (0.26 per 1000), followed by Canada (0.25 per 1000) and Greenland (0.25
Fig. 4. The EAPC of depression ASR from 1990 to 2017, both sexes, by region, and by types. 5
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Fig. 5. Contribution of major depressive disorder and dysthymia to absolute depression incident cases, both sexes, globally and by region, in 1990 and 2017.
treatment (Cerutti et al., 2016). People diagnosed with HIV/AIDS often face social stigma and restrictions in employment and marriage, which in some cases leads to divorce and family exclusion (Ironson et al., 2017). People with HIV may experience depression for many reasons, such as over concern about disease progression, pain, and death (Junqueira et al., 2008). These characteristics of the situation in Lesotho mean that preventing AIDS could be a key measure to control depression. The ASR increased the most in Belgium, followed by Guyana and South Korea. More research is needed to understand the causes of increased ASR in depression in these countries. The country with the largest reductions in ASR was Cuba, followed by Denmark and Estonia. The ASR increased significantly in the high-SDI region and high-income North America (EAPC = 0.41, 95% CI = 0.31 to 0.51). The rapid increases in the ASR of depression in these regions could be due to them having high levels of economic development, education, and social pressure. Studies have found that education can affect cognitive ability. It can affect depression in individuals and even in spouses (Lee, 2011). Social stress is also a recognized risk factor for depression (Smith, 2014). Our findings show that the proportions of both types of depression were essentially stable both globally and regionally, with a large proportion of patients having major depressive disorder. As the most common cause of disability affecting nearly 16% of the global population (Kessler et al., 2003), major depressive disorder is attracting increasing attention. A WHO report predicted that major depressive disorder will become the leading cause of disability in the world by 2030 (Yang et al., 2015), and stated that controlling major depressive disorder is the best way to address depression. Regarding the ASR of dysthymia, although this has decreased the most in the United States, that country still had the highest ASR in 2017. This shows that the United States should pay more attention to this problem and continue to take measures aimed at controlling dysthymia. The ASR of dysthymia decreased the most in the high-SDI region and high-income North America, while the ASR of major depressive disorder increased the most in these areas. This might be because some of the patients with dysthymia in these areas progressed to major depressive disorder. This study identified that there are especially high rates of depression in some countries and regions, indicating the importance of identifying the underlying reasons. Although the pathogenesis of depression is unknown, some studies have identified risk factors for depression. Depressed people have a genetic predisposition, with the risk of
per 1000) (Fig. S5), and lowest in Colombia (0.13 per 1000), followed by Romania (0.15 per 1000) and Panama (0.15 per 1000). The number of incident cases of dysthymia worldwide increased from 10 million in 1990 to 16 million in 2017, representing an increase of 58.98%. The increase was largest in Qatar (601.91%), followed by the United Arab Emirates (547.94%) and Bahrain (250.72%) (Fig. S6, Table S5). The number of incident cases decreased from 1990 to 2017 in 11 countries, by the most in Georgia (−27.65%), followed by Latvia (−22.52%) and Lithuania (−15.44%). The increase in ASR across the 195 countries and regions was largest in Iran (EAPC = 0.12, 95% CI = 0.06 to 0.21), followed by India (EAPC = 0.11, 95% CI = 0.09 to 0.13) and Portugal (EAPC = 0.11, 95% CI = 0.05 to 0.16) (Fig. S7). The decrease in ASR was largest in the United States (EAPC = −0.33, 95% CI = −0.43 to −0.24), followed by Colombia (EAPC = −0.21, 95% CI = −0.25 to–0.16) and Singapore (EAPC = −0.21, 95% CI = −0.31 to −0.09). The number of dysthymia cases in the five SDI regions increased between 1990 and 2017. However, the ASR only increased in the highmiddle-SDI, low-SDI, and low-middle-SDI regions, and decreased in the high-SDI and middle-SDI regions (Fig. 2, Table S1). The number of dysthymia cases increased in all geographical regions (Fig. 3), by the most in Western sub-Saharan Africa (130.23%), followed by Central sub-Saharan Africa (130.04%) and Eastern sub-Saharan Africa (117.02%). The ASR increased significantly in South Asia (EAPC = 0.09, 95% CI = 0.07 to 0.11) and decreased significantly in high-income North America (EAPC = −0.31, 95% CI = −0.39 to −0.22) (Fig. 4, Table 1).
4. Discussion Depression is a major public health problem and a major cause of disability (Ferrari et al., 2013). This study used data published in the GBD database to analyze the trends in depression from 1990 to 2017 and the global burden of depression. The results of this study can be used by governments in all regions to develop appropriate preventive measures for depression. This study found that the number of incident cases of depression worldwide increased by 49.86% from 1990 to 2017. The ASR was highest in Lesotho, which is a poor landlocked country surrounded by South Africa that has the third highest rate of HIV infection in the world, the highest rate of HIV transmission among the high-prevalence countries of southern Africa, and the lowest coverage of antiretroviral 6
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doi.org/10.1016/j.jpsychires.2019.08.002.
depression being significantly higher in relatives of depressed people—especially their first-degree relatives—than in the general population (Mullins and Lewis, 2017). Research has shown that age and gender are also linked to depression, with women more likely to suffer from depression than men, and older people more likely to suffer from depression as a result of more underlying illnesses (Faravelli et al., 2013; Zhao et al., 2012). In addition to genetic and psychological factors, studies have found that unhealthy lifestyles such as smoking and alcohol consumption increase the risk of depression (Gravely-Witte et al., 2009; Pavkovic et al., 2018). In addition, insomnia reportedly increases the risks of depression and anxiety (Li et al., 2016). Numerous studies have shown that certain diseases are related to the occurrence of depression. Depression is one of the most common neuropsychiatric consequences of stroke, affecting about one-third of stroke patients (Hackett et al., 2005). The prevalence of depressive symptoms in cancer patients exceeds that in the general population, and depression is associated with a poor prognosis in cancer patients (Sotelo et al., 2014). It has been found that children and adolescents with enterovirus infection are susceptible to secondary depression (Liao et al., 2017). The risk of depression is also higher in AIDS patients than in the general population (Elbadawi and Mirghani, 2017). The governments of countries with high rates of depression need to focus on supporting relevant research to identify the underlying causes and take measures to actively control the occurrence of depression. Healthy lifestyles such as increasing the amount of physical exercise and giving up smoking and drinking should be advocated. Patients with stroke, cancer, AIDS, and other diseases should be followed up and provided with appropriate medications to prevent the occurrence of depression. Medication and psychological interventions should be applied to people who are already suffering from depression in order to prevent suicidal behavior. This study has performed the most comprehensive assessment yet of the burden of depression. However, it was also subject to some limitations. Firstly, the analyzed data were obtained from the GBD database, in which depressive disorder is classified into major depressive disorder and dysthymia, and so we were only able to analyze the global burden of depression according to this classification method without further subdivision. Secondly, only the global disease burden of depression was analyzed, and the risk factors of depression in different countries and regions were not addressed. Future studies are needed to focus on this issue in order to guide the development and implementation of specific policies for controlling depression in different countries and regions.
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5. Conclusion Depression affects the mental and physical health of patients and, as the most common mental illness, has become an important public health problem. The findings of this study on the global burden of depression from 1990 to 2017 will help governments around the world to understand their own burdens of depression, and to formulate and implement measures for the prevention and early treatment of depression. Conflicts of interest The author reports no conflicts of interest in this work. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Appendix A. Supplementary data Supplementary data to this article can be found online at https:// 7