By Asst/P Yong Ming Lee
Psychology and Child & Human Development Academic Group, NIE, NTU
Published: 03 November 2022


Overview of Depression

Different word forms of “depression” can have different meanings. To the lay person, being “depressed” means feeling sad or more sad than usual. People are expected to experience feelings of sadness to different degrees in response to negative life events. However, in the clinical sense of the word, a diagnosis of a depressive disorder indicates the presence of intense and persistent sadness, in addition to physiological and cognitive symptoms, such as a loss of interests and pleasure, concentration difficulties, and low self-worth. In young people (between the ages of 7 and 21 years old), sadness can also manifest as increased irritability (Hammen et al., 2014). A diagnosis of a depressive disorder in youth should be based on careful evaluation of their presenting symptoms, daily and school functioning, as well as family, developmental, social, and educational history.

In the school setting, students with depressive symptoms are easily missed or misunderstood due to the internalizing nature of the symptoms, which may not be salient and are hard to observe (Dowdy et al., 2013). Examples are appearing sad, social withdrawal and avoidance of social contacts, reduced participation, low motivation, deteriorating academic progress, and irregular attendance. For some, their irritability could also make them prone to conflicts with peers and teachers and exhibit outbursts of emotions. 


The Singapore Context

A systematic literature search of research studies investigating mental health and emotional well-being in Singapore revealed that only one was focused on children who were 8-12 years old (Magiati et al., 2015). Using self-report rating scales, they estimated depression to be 16.9%. So far, no study has investigated the adolescent population (12-17 years). The Singapore Mental Health Survey is conducted every 5-6 years but only for those aged 21-49 years old. Relying on estimates from overseas, the lifetime prevalence rate of depressive disorders is approximately 17% (Kessler et al., 2005) and the prevalence in adolescents is about 11% (Avenevoli et al., 2015). The rate of depression increases rapidly from childhood to adolescence with a consistent gender difference showing that girls are more vulnerable to depressive symptoms. The first onset of a depressive episode is estimated to occur during adolescence (Avenevoli et al., 2015). Hence, it is likely during the period of secondary education in Singapore that many individuals will experience their first episode of depressive disorder.

More than 50% of youth with elevated depressive symptoms may experience a recurrent and protracted course of the illness, especially when comorbid with other challenges, such as anxiety conditions, conduct problems, self-harm behaviors, eating disorders, sleep issues, and suicidal ideation (Hammen et al., 2014; Fergusson & Woodward, 2002). Early experience of depression is also predictive of more severe mental illnesses and functional impairment later in adulthood. According to results from the WHO World Mental Health surveys, depression is ranked first among other disabilities as the cause of ill health across 28 countries (WHO, 2017). 


In Practice

With the onset of the COVID-19 pandemic, concerns for the mental health of youth have intensified in Singapore, as with the rest of the world (Fegert et al., 2020, Yong & Suh, 2022). The effects of the pandemic remain widespread and pervasive across health, economic, political, education, and social structures of the society. Research has identified stressors related to health concerns, social restrictions, future uncertainty, and resource constraints directly and indirectly impacting young people. In Singapore, the inter-agency COVID-19 Mental Wellness Taskforce estimated the prevalence of depressive disorders in adults between 21-49 years old to be 8.7% which appeared to be lower compared to other countries (MOH, Singapore, 2021). The youth population was excluded from this survey. Another study investigating the prevalence of depression in university students in Singapore during COVID-19 estimated the prevalence to be 29%-34% based on a self-report measure of depression. These numbers were found to be comparable with those from other studies conducted overseas (Yong & Keh, 2022).

The psychological impact of COVID-19 is significant for students as they need to adjust quickly to various stressors on top of having to negotiate various developmental tasks, related to academic demands, interpersonal relationships with peers and adults, and identity exploration and formation. As we learn to live with COVID-19, the progressive lifting of various COVID-19 mitigation measures after about two years is also associated with a series of changes and stressors that can challenge individual adjustment. For example, students can take off their masks in school, participate in sports and activities with peers from different classes and schools, assemble in bigger groups for events, move and interact freely with others during breaks. While these are positive changes that will see the return of social opportunities, some students may react with adjustment issues that could contribute to the emergence of depressive symptoms due to increased social demands.

Early identification, prevention, and treatment are important interventions for depressive disorders so that affected students can recover quickly and will not risk more severe illness and impairment that could lead to a negative trajectory of development. However, underrecognition of the severity of depression is often a barrier for seeking professional help (Jorm, 2012). Even though students generally prefer to seek support from their families and friends, compared to mental health professionals, informal support while necessary, will not be sufficient for coping with significant problems of depression (Picco et al., 2016; Jorm & Wright, 2007). Additionally, not having timely and effective treatment can lead to feelings of hopelessness and negative identity in young people.

Evidence-based treatments of depressive disorders include antidepressant medication, cognitive behavioral therapies, and interpersonal therapy (Ruderman et al., 2013). However, these options are not commonly known or easily accessible by students and their parents in Singapore. The current focus on promoting mental health literacy and resilience via the school curriculum, building peer support, and providing youths with online resources are important primary prevention initiatives that target the wider school community. Outreach programmes such as Response, Early Intervention, Assessment in Community Mental Health (REACH) and Community Health Assessment Team (CHAT) may be limited in providing the intensity and dosage of treatment needed to produce enduring positive outcomes. Helpline and hotline services are considered a type of one-off crisis intervention that does not address underlying psychopathology. As noted by the COVID-19 Mental Wellness Taskforce, there is a need to improve accessibility and sustainability of mental health services (MOH, Singapore, 2021) and this should include evidence-based treatments of depression. 



Currently, there is an urgent need to assess and monitor the mental health needs of students, especially those in secondary and tertiary educational institutions. The paucity of prevalence estimates of depression in the young population of Singapore is limiting our understanding of depression as experienced by our students. Having empirical data about depression can also help us to monitor and evaluate the effectiveness of various public mental health programmes and initiatives.

Systematic efforts to increase the mental health literacy of students should include a focus on helping students and adults around them recognize the severity of depressive disorders and relate this to various help-seeking and treatment options (Jorm, 2012; Persson et al., 2021). It will be empowering for students to understand when and how to seek informal or/and formal support for their problems.

While a wide range of informal support and primary prevention level interventions are available to all students, it is important for effective evidence-based treatment of depression to be available and accessible by a smaller group of students and their families coping with depression. Such mental health services are already integrated within the existing infrastructure of health services. However, given the low rate of professional help-seeking (Ng, Fones, and Kua, 2003), more research is needed to understand barriers to accessibility of services in the local context. 




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