Objective: Several studies conducted in high-income countries have found an association between depressive symptoms and risky behaviours among adolescents. Evidence from low- and middle-income countries (LMICs), where 90% of the world’s adolescents live, remains scarce. The objective of this review was to systematically review the evidence examining the association between depressive symptoms and risky behaviours among adolescents in LMICs. Method: We searched 15 electronic databases for published or unpublished cohort and case-control studies about adolescents in LMICs. We applied no restrictions on date or language. The primary outcome was the association (odds ratio [ORs]) between depressive symptoms and risky sexual behaviour and substance use. Secondary outcomes included delinquency, adverse school behaviour, self-harm, and suicidal behaviour. We pooled the ORs from all studies using the random-effect model. We assessed the quality of the studies using the Newcastle-Ottawa scale, and the strength of the overall body of evidence using GRADE. The study protocol was registered on PROSPERO (CRD42019131262). Results: The searches yielded 31,148 potentially relevant studies. After screening, we included 33 records in the systematic review, of which 30 comprised the meta-analysis. All studies encompassed a total of 35,918 adolescents living in 17 LMICs: 5 from Africa, 7 from Asia, and 5 from Latin America and the Caribbean. We found that adolescents with depressive symptoms are more likely to engage in risky sexual behaviour (OR 1.3, 95% CI: 1.1-1.5) and substance use (OR 1.8, 1.4-2.2) compared to non-depressed adolescents. Results for the secondary outcomes showed a similar pattern, with higher delinquency (OR 3.2, 1.8-5.6), self-harm (OR 4.4, 1.3-14.4), and suicidal behaviour (OR 6.6, 2.3-18.9) among adolescents with depression compared to healthy adolescents. Conclusion: This study suggests that adolescents with depression in LMICs carry a double burden: they both suffer from depression, and are at an increased risk of engaging in risky behaviours. This combination may lead to further psychological and physical health problems that persist over the life course, and may impose a health burden on society as a whole. Taken together, these findings highlight the urgent need for scalable and sustainable approaches to prevent and/or treat depression among adolescents in resource-poor settings.
Journal of the American Academy of Child and Adolescent Psychiatry