Original Article

Depression, Anxiety and Stress among Adolescent Students

Belonging to Affluent Families: A School-based Study
Sanjiv K Bhasin, Rahul Sharma1 and N.K. Saini

Department of Community Medicine, UCMS and GTB Hospital, 1Department of Community Medicine, VMMC and
Safdarjung Hospital, Delhi, India

ABSTRACT
Objective. To study depression, anxiety and stress (DAS) among adolescent school students belonging to affluent families
and the factors associated with high levels of DAS.

Methods. 242 adolescent students belonging to class 9-12th selected for the study. DASS-21 questionnaire was used for
assessing DAS.

Results. The scores in the three domains (DAS) were found to be remarkably correlated. It was seen that depression was
significantly more among the females (mean rank 132.5) than the males (mean rank 113.2), p=0.03. Depression
(p=0.025), Anxiety (0.005) and Stress (p<0.001) were all significantly higher among the ‘board classes’ i.e., 10th and 12th as
compared to the classes 9th and 11th. All the three (DAS) were found to have an inverse relationship with the academic
performance of the students. Depression and Stress were found to be significantly associated with the number of adverse
events in the student’s life that occurred in last one year.

Conclusion. A significant proportion of the students were found to be having high levels of DAS and several important factors
were found to be associated with them. Proactive steps at the school-level and community-level and steps for improved
parent-adolescent communication are needed for amelioration of the problem. [Indian J Pediatr 2010; 77 (2) : 161-165]
E-mail: sanjivsk1bhasin@rediffmail.com

Key words: Depression; Anxiety; Stress; Adolescents; Students

Adolescence is a crucial phase in life and the presence
of conditions like depression, anxiety and stress at this
stage of life is a matter of concern. Depression in this
population has been shown to be associated with
increased risk of suicidal behavior, homicidal ideation,
tobacco use and other substance abuse into adulthood.1
It has been noted that the majority of suicides in India
are by those below the age of 30 years and also that
around 90% of those who die by suicide have a mental
disorder.2
Increasing concern has been expressed about the
mental health of students in higher education.
Concerns have been articulated by students themselves
and by the academic staff who teach them.3 The World
Health Report has quoted India as having a substantial
Correspondence and Reprint requests : Dr. Sanjiv K. Bhasin,
Professor, Department of Community Medicine, University
College of Medical Sciences and GTB Hospital, Dilshad Garden,
Delhi-110095, India.
[DOI-10.1007/s12098-009-0260-5]
[Received December 08, 2008; Accepted April 16, 2009]
prevalence of childhood and adolescent mental health
disorders. 4
The present study was carried out with an objective
to study the levels of depression, anxiety and stress
(DAS) among school students belonging to affluent
families, and the association with various socio-
demographic characteristics of the students. The
hypothesis was that the DAS levels would be high in
the ‘Board’ years, that is 10th and 12th compared to 9 th
and 11th.
MATERIAL AND METHODS
The study was an institution based study undertaken
in the year 2007. Permission for carrying out the study
was obtained from the institute ethics committee. A
school having students mostly belonging to affluent
families was purposively selected in Greater Noida,
Uttar Pradesh, a township within the National Capital
Region (NCR). The study included all available

Indian Journal of Pediatrics, Volume 77—February, 2010 161

 Sanjiv K. Bhasin et al
students of classes 9-12 th in the school. A written
consent was taken from the Principal prior to conduct
of the study. In each class, informed consent from the
students was taken after being explained about the
purpose of the study and that their responses would be
kept confidential. All students in the selected classes,
present on the day of the survey, were eligible to
participate allowing for confidential and voluntary
participation.
The self-administered Depression, Anxiety and
Stress Scale (DASS) questionnaire was used along with
a socio-demographic questionnaire to collect data. The
DASS is a set of three self-report scales designed to
measure the negative emotional states of depression,
anxiety and stress. 5 In addition to the basic 42-item
questionnaire, a short version, the DASS21, is available
with 7 items per scale.6 It has been mentioned that as
the essential development of the DASS was carried out
with non-clinical samples, it is suitable for screening
normal adolescents and adults. In each item, the
respondents are to rate the extent to which they have
experienced the given state over the past week, using a
4-point severity/frequency scale. Scores for Depression,
Anxiety and Stress are calculated by summing the
scores for the relevant items.7 In the present study the
short (21-item) version of of DASS was used. As
recommended, the obtained scale scores are multiplied
by 2, to make them comparable to the DASS normative
data scores. The DASS questionnaire has been used
earlier among both school and university level
adolescent students. 8-10 The validity and reliability of
the DASS questionnaire in measuring the dimensions
of depression, anxiety, and stress has been proved in
different studies, and several are listed at the official
website.11-13
The statistical tests employed included Kruskal-
Wallis test for the survey data. The Kruskal-Wallis test
is used for comparing non-normal variables, and is a
generalization of the Mann-Whitney U test. It works by
assigning a rank to each score in a scale, and then
comparing the mean rank score of the different
categories of the grouping variable under consideration.
All the scores are considered together as a single N,
and each score is assigned a ‘rank’ with the highest
score getting the highest rank. (=N) and lowest getting
rank=1. Further detailed reading on the Kruskal-Wallis
test is available.14,15 Tests for significance of correlation
were applied to test the association of DASS scores with
numerical scale variables.
RESULTS
The total number of respondents in the survey was
242. No refusal to participate. 3 forms were excluded
162
from analysis as they were incomplete. The age of the
students ranged from 13-18 years (mean 15 ± 1.1 years).
Among the students, 138 (57.0%) were males. The
respondents included 47, 70, 64 and 61 from class 9th,
10th, 11 th and 12th respectively. A large majority of the
students were Hindu (91.7%). Nearly 80% of the
students (194) belonged to nuclear families. Most (232)
were residing with their own family, with only 10
(4.1%) living in hostel or with guardians. A majority
(225, 93.0%) had mothers who were graduates.
Regarding the mothers’ occupation, a majority (66.8%)
were home-makers. Only four (1.6%) reported having a
parent not alive, which precluded meaningful analysis
of association with DAS.
The results of the DASS scores are portrayed in Table
1. As can be seen, a wide range was seen in the DASS
TABLE 1. Summary of the DASS Scores Amongst the Respondents (n=242)
Depression Anxiety Stress
Range of score possible 0-42 0-42 0-42
Minimum score among the students 0 0 0
Maximum score among the students 42 32 40
Mean (Standard deviation) score 11.9 (8.3) 9.0 (6.8) 15.5 (8.1)
Median score 10 8 14
Correlation between the scores in
the three domains
Depression 1.00 0.454* 0.647*
Anxiety 0.454* 1.00 0.586*
Stress 0.647* 0.586* 1.00
* Correlation is significant at the <0.001 level (2-tailed).
(Figures for correlation represent the Pearson’s correlation coefficient)
scores of the students. However, the scores in the three
domains namely Depression, Anxiety and Stress were
found to be remarkably correlated. It was seen that
depression was significantly more among the females
(mean rank 132.5) than the males (mean rank 113.2),
p=0.03. Anxiety and Stress scores were however not
significantly different between the two genders. On
analyzing the association with the academic class,
interesting findings emerged. The mean ranks of DASS
scores were all significantly higher for Depression
(p=0.025), Anxiety (0.005) and Stress (p<0.001) among
the ‘board classes’ i.e., 10th and 12th as compared to the
classes 9th and 11h (the mean ranks of score being 130.8
and 110.6 respectively for D, 133 and 108 respectively
for A and 139.5 and 100.3 respectively for S). No
significant association was observed with the type of
family (nuclear or joint) or mother’s education level
(graduate or lesser) or income group of the
respondent’s family. The levels of D (mean rank 128.4
versus 117.3, p=0.25), A (mean rank 125.3 versus 118.9,
p=0.5) and S (mean rank 128.9 vs 117.1, p=0.21) were
all seen to be higher among students with working
mothers than the students whose mothers were
housewives, though the differences were not
statistically significant.
The students were asked to mention their marks in
Indian Journal of Pediatrics, Volume 77—February, 2010
 Depression, Anxiety and Stress among Adolescent Students Belonging to Affluent Families

the last annual examination. All the three (D, A and S) adverse events in life.
were found to be higher among those having lesser
The association of DAS with parent-adolescent
academic performance (Table 2). A strong association
relationship is depicted in Table 4. Students who
was observed with taking tuitions for any subject. Among
reported that their parents pressurized them to study
the students, 145 (60%) were receiving tuitions in some
sometimes or often, had significantly higher Depression
TABLE 2. Association of the DASS Scores with Academic (p=0.001) and Stress (p=0.03) than those reporting as
Performance and with Taking Tuitions Amongst
the Respondents (n=238)*
TABLE 4. Association of the DASS Scores with Various
Grouping variable Kruskal-Wallis test Mean Aspects of Parent-adolescent Relationship (n=242)
ranks
Kruskal-Wallis test Mean
Academic marks Number Depression Anxiety Stress ranks
of
Number Depression Anxiety Stress
students
of
Less than 80% 93 128.58 133.67 128.75 students
80’s (80-89%) 99 117.50 112.61 114.82
Parents pressurize to
90’s (90% or higher) 46 105.45 105.68 110.88
study
p value for difference 0.16 0.03 0.23
Never or Rarely 97 102.56 115.91 109.73
in mean ranks
Sometimes or Often 145 134.17 125.24 129.38
Receiving tuitions for
p value for difference 0.001 0.31 0.03
any subject
Discuss personal
No 97 109.25 109.63 102.95
problems with parents
Yes 145 129.69 129.44 133.91
Never or Rarely 136 136.41 130.67 134.63
p value for difference 0.03 0.03 0.001
Sometimes or Often 106 102.37 109.74 104.66
in mean ranks
p value for difference <0.001 0.02 0.001
* Four students had not mentioned their marks Father or mother beats physically
(Figures for Kruskal-Wallis test represent the mean ranks for Never or Rarely 232 119.89 120.07 120.01
the grouping variable, for each of D, A and S) Sometimes or Often 10 158.80 154.70 156.15
p value for difference 0.08 0.12 0.11
subject. D (p=0.03), A (p=0.03) and S (p=0.001) were all Parents have a fight among themselves
likely to be significantly higher in the students taking Never or Rarely 196 113.24 114.88 112.90
tuitions, compared to those who were not (Table 2). The Sometimes or Often 46 156.68 149.70 158.14
p value for difference <0.001 0.002 <0.001
relationship with taking tuition held, even after taking
into consideration the academic level of the students. (Figures for Kruskal-Wallis test represent the mean ranks for
the grouping variable, for each of D, A and S)
The association with adverse events in life (AEL)
was also tested as part of the study. The students were
never or rarely. Discussing personal problems with
asked whether any of five adverse events had occurred
parents was found to be a strong support mechanism.
in their family in the last one year, namely: death of any
All the three outcome measures of interest (D, A and S)
family member, any major accident, any major fight, any
were higher among students whose parents inflicted
TABLE 3. Association of the DASS Scores with Adverse physical violence on them, and among students whose
Events in Family of Respondent within Last One parents fought among themselves regularly.
Year (n=242)
Grouping variable Kruskal-Wallis test Mean
ranks DISCUSSION
Number of Adverse Number Depression Anxiety Stress
events reported of The present study included 242 adolescents studying in
students
a purposively selected public school that had students
0 140 107.54 114.86 114.31 mostly belonging to affluent families. This was done to
1 78 140.56 128.53 123.19 rule out the influence of economic deprivation or
2 13 132.15 125.19 144.31
3 or more 11 151.41 151.82 174.14
financial stress as a cause towards DAS among the
p value for difference 0.003 0.24 0.027 students. It has been shown that financial difficulties
make a significant independent contribution to
(Figures for Kruskal-Wallis test represent the mean ranks for
depression among students. 16 Only the adolescents
the grouping variable, for each of D, A and S)
belonging to class 9-12 th were taken as the
major illness and any major surgical operation. The questionnaires were to be self-administered and would
results of association with the number of AEL reported have been difficult to understand for the lower classes.
are shown in table 3. Depression and Stress were The higher socio-economic background of the students
found to be significantly associated with the number of is also portrayed by the fact that mothers of 93% of the

Indian Journal of Pediatrics, Volume 77—February, 2010 163

 Sanjiv K. Bhasin et al
students were graduates, and that all of them had a
separate living room for themselves. That 80% of the
students hail from nuclear families shows the growing
trend away from joint families, especially in urban
areas.
Significantly high proportions of the students were
found to be having high levels of D, A and S. Previous
studies too have found large proportions of students
(school or university level) to be having high levels of
these negative states.8,9,10,17,18 The finding that depression
was more among the female students compared to
males, is in line with the past experience. 18 Our
hypothesis that D, A and S would all be higher among
the ‘board classes’ i.e., 10 th and 12 th , compared with
class 9th and 11th was proven by the findings. It is a stark
reminder of the tremendous pressure faced by the
students with regards to their performance in the board
exams. It is a shortcoming of the society that undue
emphasis is placed on just the results of the two board
exams, which is taken as a measure of their entire
academic caliber. This is leading to the higher levels of
negative mental states like D, A and S among the
students belonging to these classes, and that too, just at
the beginning of the academic term.
That pressure to perform well academically is a
strong predisposing factor for DAS among the students,
is also bolstered by our finding that all of these negative
states were significantly higher among the students
who had lower academic marks in their last school
exam. An interesting finding was that DAS were more
among the students taking tuitions for any subject
compared to those who were not, irrespective of the
academic level. This could also be reflective of parental
pressure (or own perceived pressure) to improve their
academic showing in the form of better marks. Bayram
and Bilgel (2008) too had found that students who were
satisfied with their education had lower DAS scores
than those who were not satisfied.8
Recent adverse life events (AEL) such as death of a
family member, accident, illness in family etc are bound to
have an effect on the DAS levels among the young
adolescents, as was seen in the present study. It points to
the fact that special care and support is needed for
students who have had recent adverse events. Both the
family and the school authorities are required to be sensitive
to the needs of such children for prop up and guidance.
Parental-adolescent relationship is a strong bulwark
for the adolescents during this delicate period of major
changes in their life. The various domains (DAS) that
we examined were found to be higher among students
whose parents frequently pressurized them to study,
whose parents fought among them, or whose parents
inflicted physical violence on their children. DAS were
also higher among the students who did not discuss
their personal problems with their parents.
164
A few limitations of our study include the fact that
students belonging to a single institute were studied,
which may impact the generalizability of the factors
found to be significant by us. Another limitation was
that the academic marks got in the last examination
were self-reported ones and could not be verified with
actual school reports as consent could not be received
for obtaining the individual academic marks of the
respondents. Though the DASS scale has been used
earlier among Indian population, specific normative
data or cutoff values were not available for the Indian
student population. Hence, we could not directly
classify the students as ‘normal/abnormal’ or obtain
figures for the prevalence of DAS. This limitation was
overcome by us by utilizing suitable statistical tests for
analysis that give ranking to the scores obtained and
are not dependent on classification.
The utility of the present study lies in pointing out
that there exist several factors for DAS among the
adolescent students, even among those from relatively
affluent family backgrounds. Pediatricians and other
health professionals working with adolescents and the
educational institutions need to be aware of and
responsive to the presence of these negative mental
health states among the students so that early
amelioration may be offered to the adolescents.
The depression, anxiety and stress among the
students were found to be quite high, and many
aggravating factors were found to be associated with
higher levels of DAS among the students. There is a
need for special focus on the adolescent population
and their mental health. Educational institutions need
to identify the prevalence of negative mental health
states among the students, and especially those at high
risk. Understanding the prevalence of DAS and the
possible factors associated with higher levels of DAS
would help in the designing and provision of school-
based or community-based counseling and treatment
options exclusively for the adolescents. This would go
a long way in ensuring that the adolescent students are
able to emerge as healthy adult citizens of the nation.
Contributions: SKB conceptualized, designed, supervised data
acquisition, analysed data and prepared, edited manuscript. RS
contributed to study design, data acquisition, analysis and
manuscript preparation and editing. NKS contributed to study
design, data analysis, manuscript editing and review.
Conflicts of Interest: None.
Role of Funding Source: None .
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