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Epidemiology of depression in the Asia Pacific region

Edmond Chiu

Objective:

To summarise studies reporting rates of depression (for thegeneral population and older samples) and suicide in the Asia Pacific region.

Methods:

Information on local data was collected from the members ofthe SEBoD International Advisory Board on known epidemiological studies.Additionally, online searches were conducted using Medline and PsycInfo forthe period 1994–2004.

Results:

Across the Asia Pacific region, rates of current or 1-month majordepression ranged from 1.3% to 5.5%, rates of major depression in theprevious year ranged from 1.7% to 6.7%, and lifetime rates ranged from1.1% to 19.9%, with a median of 3.7%. Rates of suicide in the Asia Pacificregion are now similar to those in Europe and the Americas. The exceptionsinclude China and South Korea.

Conclusions:

Epidemiological studies in Asian populations are rare and usevarious diagnostic criteria. However, studies indicate that rates of depressionin Asia Pacific, whilst lower, are comparable to other western countries.As such, depression as a health issue in Asia Pacific demands greater recog-nition. It is important that Asian countries should have the human andfinancial resources to conduct large scale epidemiological surveys not only inthe area of depression, but also in the broader field of mental disorders.

Key words:

depression, epidemiology, suicide rates.

INTRODUCTION

hile clinicians, on an individual level, identify, diagnose andtreat depression, the over-arching picture of depression in thecontext of a country requires the contribution of epidemiology

– the study of diseases in populations. In Asia, the science and practiceof epidemiology in mental disorders have been lagging behind for themost important and urgent communicable diseases. When the WorldBank and World Health Organization (WHO) identified the ‘burden ofdiseases’, with major depression high up in the list for developingnations, the interest in epidemiology of depression and its treatmenttook on a higher profile in health planning and policy.

1

However, asepidemiological studies require financial, human and social resourcesand infrastructure to plan, conduct and complete, Asian nations have yetto deliver up-to-date epidemiological data on depression. This articleaims to provide an overview of studies conducted to date on theepidemiology of depressive disorders across the Asia Pacific region.

METHODS

Initially, members of the SEBoD International Advisory Board wererequested to provide information on local studies of the epidemiology ofmental health. This strategy was employed because many of the Asianepidemiological studies are published in local journals in the language ofthe country of origin, and are not readily accessible in English languagejournal databases. In addition, online searches were conducted usingMedline and PsycInfo for the period 1994–2004. Finally, some data are

Professor Edmond Chiu AM

Professor of Old Age Psychiatry, Academic Unit for Psychiatry of Old Age, University of Melbourne, Normanby House, St. George’s Hospital, 283 Cotham Road, Kew Victoria 3101, Australia.

Correspondence

: Professor Ian Hickie, Brain & Mind Research Institute, PO Box M160, Camperdown NSW 1450, Australia.Email: ianh@med.usyd.edu.au

W

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presented from official reports prepared by the localMinistries of Health, in either English or the languageof the country of origin.

Such data point to a broad picture of the epidemiol-ogy of depression, which may or may not have thenecessary ‘scientific vigour’ established by the devel-oped world. Nevertheless, the results are consideredvalid in their own right as essential descriptions of anemerging pattern of depression within each country,to be accepted, interpreted and deployed in health-care planning and policy development.

RESULTS

Information on the epidemiology of depression ispresented for nine countries in the Asia Pacificregion. Online searches of data from Indonesia, Phil-ippines, North Korea and Vietnam had not yieldedany information at the time of writing.

Australia

The Australian National Mental Health and Wellbeing Survey conducted in 1997 provided mentalhealth epidemiological data from a study of 10 641people across Australia using the Composite Inter-national Diagnostic Interview (CIDI) to provide bothICD-10 and DSM-IV diagnoses.

2

A total of 17.7% ofthe sample had one or more ICD-10 defined mentaldisorders and 5.8% of the adult population hadone or more depressive disorders (4.2% in men and7.4% in women). The presence of comorbid mentaldisorder was reported in 66% of men and 57% ofwomen.

2

When the prevalence of any ICD-10 diag-nosis of depressive and anxiety disorders was calcu-lated, the rate for men was 9.9% and for women16.9%, giving a total rate of 13.5%.

3

China

The first major epidemiological survey of mentaldisorders in China was conducted as a large-scalejoint project between the WHO and 12 Chineseresearch centres and was completed in 1982.

4

Bothurban and rural household samples (500 householdseach per centre comprising a total sample of 51 982people) were studied (using the Present State Exami-nation) making it one of the largest studies under-taken in the developing world. The mean prevalencerate for depressive neurosis in China was estimated as3.1 per 1000 (4.1 per 1000 in subjects from rural areasand 2.1 per 1000 from urban areas). In contrast todepressive neurosis, neurasthenia prevalence ratewas calculated at a mean of 13.0 per 1000. A secondnational survey, conducted in 1993, identified analmost identical point prevalence of depressive neu-rosis of 0.3% (or 3.0 per 1000), a slightly higherprevalence of affective psychosis 0.1% (0.03% in the1982 survey), and a lower prevalence of neurasthenia0.8% (or 8.4 per 1000).

5,6

Xiao and colleagues reported on the Chinese sub-sample from a 15 country WHO Collaborative Studyon the prevalence and treatment of depression.

7

TheShanghai sample included 583 outpatients from aDepartment of International Medicine. The GeneralHealth Questionnaire (GHQ-28) was used to screensubjects and a psychiatrist made diagnoses using theCIDI. Depressive disorders were the most commondiagnoses, with the rate of ICD-10 major depressionat 4% and dysthymia at 0.6%. Another study con-ducted in Shanghai used the Chinese Classification ofMental Disorders (CCMD-2) criteria in a sample of3880 people.

8

The reported prevalence of depressionwas 0.7%, and 19.9% of the sample had symptoms ofdepression. Almost 60% (59.7%) of the group aged36–55 years reported depressive symptoms, as did themajority (79%) of subjects who had received primaryand secondary education.

Following establishment of the WHO World MentalHealth (WMH) Survey Consortium in 1998, surveyswere conducted in the People’s Republic of Chinaduring 2002–03.

9

In Beijing and Shanghai, randomsamples of 2633 and 2568 subjects, respectively, wereinterviewed using the WMH-CIDI. The 12-monthprevalence of DSM-IV mood disorders (includingbipolar disorder, dysthymia and major depressivedisorder) was 2.5% in Beijing and 1.7% in Shanghai.

The reported rate of depression in older people inChina varies between 1.5% (based on a sample of 2885using DSM-III-R criteria),

10

to a high of 4.9% (CCMD-2R criteria).

11

Li and colleagues

12

reported a prevalenceof 3.8% in 1553 participants over 60 years using ICD-10 criteria and Tang and colleagues

13

2.6% in 5385subjects aged over 55 years using CCMD-3 criteria.

Abstracting such varied data is not an easy task for acountry with the immense diversity of a population ofover 1 billion people. However, the trend in the morerecent data reveals the prevalence of depression in thegeneral population ranges from 0.3% up to 4%.

Hong Kong (People’s Republic of China)

Chen and colleagues reported on a large communitysurvey (

n

= 7229) of mental disorders in Shatin.

14

Using the Diagnostic Interview Schedule (DIS-III),lifetime prevalence of DSM-III major depressive dis-order was calculated as 3.7% (1.3% for men and 2.4%for women), and of dysthymic disorder as 3.9% (1.1%for men and 2.8% for women). The prevalence ofgeneralised anxiety disorder, tobacco dependenceand alcohol abuse and dependence were particularlyhigh in this population. There appeared to be an ageeffect, with the highest prevalence rate of depressionin men aged 18–24 years (2.3%) and women aged25–44 years (2.8%).

Recent unpublished telephone data was collectedafter September 11 2001 and following the SevereAcute Respiratory Syndrome (SARS) outbreak (Lee S,

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pers. comm., 2003). Mood disorders were defined asthe persistent experience of at least 4 somatic oremotional symptoms with impairment of socialfunction during the previous 4 weeks. The formertelephone survey reported 17.6% of respondentsexperiencing mood disorders, with a male to femaleratio of 41:59. In the post-SARS survey of 1250respondents conducted in May 2003, 19% of respond-ents suffered from mood disorders (10.7% of men and26.5% of women).

Japan

In Japan, psychiatric epidemiology is still in the‘neonatal’ stage, with only a few studies employingstructured diagnostic interview and/or operationalcriteria.

15

A study in primary care using DSM-IVdiagnostic criteria in 7029 outpatients gave a preva-lence of major depressive episodes of 1.3%, with aprevalence of subthreshold status of 0.9%.

16

Thisstudy also investigated the relationship betweencomplaints of headache and chronic fatigue andidentified that these symptoms showed statisticallysignificant association with depression. Of 278patients with headache complaints, 30 had majordepression as their diagnosis (11%) while 33 peopleout of 157 (21%) with complaints of chronic fatiguehad an associated diagnosis of major depression.

During 2002–2003 the WHO conducted WMH sur-veys, including a sample of 1663 people aged 20 yearsand older from Japan.

9

The 12-month prevalence ofDSM-IV mood disorders (including bipolar disorder)was 3.1%.

The Tajiri project studied symptoms of depression in anelderly (65 years and greater) Japanese sample of cog-nitively intact subjects.

17

Ambo and colleagues reporteda prevalence of depression of 6.4% in their sample of1525 subjects, 4.1% in men and 8.2% in women. In thiselderly sample, the perception of economic status, aswell as a combination of physical health factors, wereassociated with the presence of depression.

17

Korea

A study of a sample of 5100 subjects using the DIS-III(Korean version) reported a lifetime prevalence rate of5.4% of affective disorders, of which major depres-sion comprised 3.4% and dysthymia 2.2%.

18

Thiscontrasts with the much higher rates of anxietydisorders (9.5%) and substance use disorders (31.8%).Alcohol abuse and dependence accounted for 22.0%,while tobacco dependence was 20.3%. Lee and col-leagues (1990) reported a lifetime rate of DSM-IIIdefined depression of 2.9% and a 12-month rate of2.3%, as well as a very high prevalence of alcoholabuse.

19

The epidemiology of DSM-IV defined psychiatricillness in Korea was studied in 2001.

20

Seven medicaluniversities and three national hospitals reviewed6242 subjects aged between 18 and 64 years using the

Korean CIDI. The lifetime prevalence of major depres-sive disorder was 4.0%, with a 1-year prevalence of1.8% and 1-month prevalence of 1.3%.

20

There was atendency towards higher rates of major depression inolder people, those who were separated, divorced orwidowed, unemployed, had low educational achieve-ment, lived in rural locations and had lower eco-nomic status. Of note is the utilisation of mentalhealth services by just over a quarter of the sample ofpeople with depression (major depressive disorderand dysthymic disorder, 26.8%), with 23% havingconsulted a psychiatrist. These rates are in sharpcontrast with those found in the entire sample ofpeople with a psychiatric disorder, only 8.9% hadused a mental health service and 7.8% had consulteda psychiatrist. Use of pharmacotherapy was alsocommon, 24.1% of people with depressive disorderswere in receipt of psychopharmacotherapy comparedwith only 8.1% of the whole sample of people with apsychiatric disorder.

Malaysia

In 1996, a National Health and Morbidity Studyinvolving 35 733 subjects was undertaken. Some 15%of this sample was suffering from either depression oranxiety as measured by the GHQ-12 and GHQ-28.

21

Singapore

The Singapore Mental Health Survey included 2947subjects (1129 Chinese, 1012 Malaysian and 806Indian people) recruited from five regions of Singa-pore.

22

The CIDI was used to determine ICD-10diagnoses. Major depressive disorder was identified in5.5% of this sample, dysthymia in 1.8% and anyaffective disorder in 7.8%.

In a separate study, Kua

23

reported the prevalence ofmental disorders in elderly Chinese in Singapore(

n

= 612) using the Automated Geriatric Examinationfor Computerised Assisted Taxonomy (AGECAT) pro-gram. The prevalence of all mental disorders was10%, with depression at 5.7%. When subthresholdcases were added, depression prevalence rose to 9.3%.

Taiwan

The doyen of Chinese psychiatry, Professor Tsung-yiLin, reported in 1953 one of the earliest epidemiolog-ical studies of mental disorders in Chinese peopleliving in Taiwan.

24

While depression was not specifi-cally listed as a distinct diagnostic entity, the preva-lence of psychoneurosis was 1.2 per 1000, and theoverall rate of mental disorder was 10.8 per 1000. Asimilar study conducted 15 years later in the samedistricts revealed a 6.5-times increase to 7.8 per 1000for psychoneurosis.

25

Since these pioneering studies,further epidemiological activities have producedanother three sets of data.

Cheng and colleagues reported on a communitystudy conducted in rural, suburban and urban areas

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of Taiwan (

n

= 1044).

26

Following screening, subjectswere interviewed by a psychiatrist using a Chineseversion of the Clinical Interview Schedule. Approxi-mately one third of women (33.3%) and one in fivemen (18%) had minor psychiatric morbidity.

During 1982–1986, the Taiwan Psychiatric Epidemio-logical Project surveyed people from metropolitanareas (

n

= 5005), small towns (

n

= 3004) and ruralvillages (

n

= 2995) using the Chinese modification ofthe DIS.

27

The lifetime prevalence of any psychiatricdisorder was 21.6%, and was highest in the smalltown samples (28%), followed by rural villages(21.5%) and metropolitan areas (16.3%). The lifetimeprevalence rate of major depression for the entiresample was 1.1%. Subjects from small towns weremost vulnerable to major depressive disorder, with a1-year prevalence of 11.4 per 1000 compared with8.1 per 1000 in the rural villages and 6.4 per 1000in the metropolitan region. Lifetime prevalence ofmajor depressive disorder followed the same pattern:small towns 16.8 per 1000; rural villages 9.7 per 1000;and, metropolitan areas 6.4 per 1000. The prevalencerates of dysthymic disorder were similar in the threesampling areas. The lifetime prevalence of generalisedanxiety disorder was high: metropolitan areas 37.4per 1000; small towns 104.9 per 1000; and, ruralvillages 77.8 per 1000. Women had higher prevalencerates in disorders related to depression, anxietyand psychophysiological problems including psycho-sexual dysfunction.

The Taiwan Old Age Depression Study included 1500subjects aged 65 years and over who were randomlyselected from rural, semi-urban and urban locationsin south Taiwan.

28

A Mandarin version of theAGECAT was used for the diagnosis of depression.The 1-month prevalence of any psychiatric disorderwas 37.7%, of depressive neurosis was 15.3% and ofmajor depression was 5.9%. Rates of depressive dis-orders were higher in women, those with less educa-tion and who lived in urban regions.

Thailand

There are few mental health professionals in Thailandwith epidemiological training. This is compoundedby the lack of accepted instruments for epidemio-logical research. Tools developed from the DIS andCIDI into Thai language as epidemiological instru-ments are at present considered controversial. Arecent epidemiological study used the CIDI to exam-ine prevalence of mental disorders in a communitysample of 2948 subjects aged 15–60 years from Bang-kok.

29

The lifetime prevalence of DSM-IV majordepressive episode was 19.9% and dysthymia was 1%.Another study, using the Thai version of the GeriatricDepression Scale, reported the prevalence of depres-sion in an elderly sample of 1713 people living infour districts in the periphery of Bangkok as 12.8%.

30

Data from the 9 countries are summarised in Table 1with results from recent epidemiological surveysin The Netherlands (Netherlands Mental Health

Table 1: Prevalence of major depressive disorder across countries

Study country Diagnostic criteria

Diagnostic instrument

Prevalence 1-month 1-year Lifetime

Australia (National Mental Health DSM-IV CIDI 3.2% 6.3% –and Wellbeing Survey)

34

ICD-10 CIDI 3.3% 6.7% –China (WHO WMH Survey)

9

† DSM-IV CIDI – 1.7–2.5% –Hong Kong (Shatin Community Mental

Health Survey)

14

DSM-III DIS-III – – 3.7%Japan (Maeno Outpatient Survey)

16

DSM-IV – 1.3% – –Japan (WHO WMH Survey)

9

† DSM-IV CIDI – 3.1% –Korea (Lee, 1986)

21

DSM DIS-III – – 3.4%Singapore (Mental Health Survey)

19

ICD-10 CIDI 5.5% – –South Korea (CK Lee, 2001)

23

DSM-IV CIDI 1.3% 1.8% 4.0%Taiwan (Psychiatric Epidemiological Project)

27

DSM-III DIS-CM – – 1.1%Thailand

29

DSM-IV CIDI – – 19.9%The Netherlands (NEMESIS)

31

DSM-III-R CIDI 2.7% 5.8% 15.4%United States (National Comorbidity Survey)

32,33

† DSM-III-R CIDI 4.9% 10.3% 17.1%

†

WHO WMH Survey and the National Comorbidity Survey report all mood disorders including bipolar disorder.

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Survey and Incidence Study, NEMESIS)

31

and theUnited States (National Comorbidity Study)

32,33

forcomparison.

Suicide in the Asia Pacific region

Suicide data reported by Phillips and colleagues basedon Chinese Ministry of Health mortality data for1995–99 showed a mean annual suicide rate in Chinaof 23.2 per 100 000.

35

The annual rate in rural areaswas high (23.9 per 100 000 for men and 30.5 per100 000 for women) compared with the urban rates(8.3 per 100 000 for men and 8.3 per 100 000 forwomen). Such a contrast cannot be easily explainedwithout more detailed research into the physicaland psychosocial risk factors for high suicide ratesin rural areas. Psychological autopsies on 519 peoplewho committed suicide during 1995–99 in Chinarevealed that 63% had a psychiatric illness at the timeof death, the most common being major depression(40%), followed by schizophrenia (7%) and alcoholdependence (7%).

36

Of the 519 people who commit-ted suicide, only 17% had sought help from a healthprofessional for a psychological problem, 7% hadseen a mental health professional, and only 9% hadused psychotropic medication in the month prior totheir death.

36

The National Statistical Office revealed that in SouthKorea, suicide was the seventh leading cause of deathin 2002 (for men it was the sixth leading cause ofdeath and for women, the seventh).

37

AmongstKorean people aged between 20 and 39 years it wasthe second leading cause of death. The total suiciderate was 19.1 per 100 000 in 2002, which represents adramatic rise from the 1992 rate of 9.7 per 100 000.The rate of suicide in 2002 is the fourth highestamongst OECD (Organisation for Economic Co-operation and Development) countries. The associa-tion between suicide and depressive disorders was notreported for these data.

Other Asia Pacific countries for which statistics areavailable show rates similar to those in Europe andthe Americas (Fig. 1). Nearly half a million people diefrom suicide in the Asia Pacific region every year,many of them in their economically productive years(Sartorius N, pers. comm., 2004). Moreover, for everycompleted suicide there are at least 10 attemptedsuicides often resulting in lasting physical impair-ment (e.g. from consequences of the intoxications ortraumas related to the attempt).

DISCUSSION

Few epidemiological studies on depression in the AsiaPacific region have been conducted. Those reviewedindicate a range of rates of current or 1-month majordepression from 1.3% to 5.5%, major depression inthe previous year from 1.7% to 6.7%, and lifetimerates from 1.1% to 19.9%, with a median of 3.7%.Comparison between countries reveals the lifetime

rate of depression being less in all Asian countriesthan that of the United States and The Netherlands,with the exception of Thailand. While there has beenrelatively little interest in, and study of, the epidemi-ology of depression and other mental disorders inAsia, some results are encouraging. For instance,mental health services were utilised by over a quarterof Koreans with depression in a recent study.

23

Thesefigures suggest the Korean population with depressivedisorders is not averse to seeking psychiatric help.A more disturbing figure is that almost a third of theSouth Korean population were diagnosed with asubstance abuse problem. This high level of substanceabuse parallels that of Chen’s Shatin Study fromHong Kong.

14

For China, there is yet to be a population-basedrepresentative national database of mental health.As such, data reported in the past may underestimatethe prevalence of depression, with recent studiesindicating a higher prevalence rate. The high suiciderate in rural women raises serious public healthconcerns and should be explored urgently and ener-getically. The figures from Phillips and colleaguesindicating almost two-thirds of people who commit-ted suicide in China had a mental disorder at the timeof death and 40% of suicide subjects had a depressivedisorder, highlights an urgent public health priorityto tackle depression in China.

36

In reviewing epidemiological data from some coun-tries in the Asia Pacific region, the most obviousobstacle is the lack of necessary infrastructure andhuman and financial resources in most countries.Large-scale surveys are difficult to accomplish underthese circumstances. Furthermore, instruments aregenerally developed and validated in Caucasian pop-ulations. For the Asian countries, the translation andrevalidation of instruments for local use continues

Figure 1: Rates of suicide in the Asia Pacific region

(Sartorius N, pers. comm., 2004).

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to be a challenge, although the Center for Epidemio-logical Studies – Depression (CES-D) scale has beenvalidated in older populations in five South-EastAsian countries.

38

When epidemiological data has been obtained, someof these studies were published within the country inits own language and often did not appear in Englishlanguage peer-reviewed journals. This prevents theaccess to the data outside the country of origin, andits contribution to the worldwide information base.Nevertheless, the available data reviewed in thismanuscript suggest a ‘ball-park figure’ of 5% of thepopulation will have a depressive disorder, with some10–15% of the population experiencing depressivesymptoms.

Depressive disorders are a rising problem in the AsiaPacific region. The burden of disease as reported bythe World Bank and the WHO is supported by suchdata, limited though they may be. It is importantthat in the coming years Asia Pacific countries shouldhave the human and financial resources to conductlarge-scale epidemiological surveys not only in thearea of depression but in other areas of mentaldisorders.

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