Systematic Review and Meta-analysis: Depressive Symptoms and Risky Behaviors Among Adolescents in Low- and Middle-Income Countries

Several studies conducted in high-income countries have found an association between depressive symptoms and risky behaviors among adolescents. Evidence from low- and middle-income countries (LMICs), where 90% of the world's adolescents live, remains scarce. This meta-analysis systematically reviewed evidence examining the association between depressive symptoms and risky behaviors among adolescents in LMICs.Fifteen electronic databases were searched for published or unpublished cohort and case-control studies about adolescents in LMICs. The primary outcome was the association (odds ratio [OR]) between depressive symptoms and risky sexual behavior and substance use. Secondary outcomes included delinquency, adverse school behavior, self-harm, and suicidal behavior. ORs from all studies were pooled using the random-effects model. Quality of studies was assessed using the Newcastle-Ottawa scale, and strength of the overall body of evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluation.Searches yielded 31,148 potentially relevant studies. After screening, 33 studies were included in the systematic review, of which 30 comprised the meta-analysis. Studies encompassed 35,918 adolescents living in 17 LMICs: 5 from Africa, 7 from Asia, and 5 from Latin America and the Caribbean. Adolescents with depressive symptoms were more likely to engage in risky sexual behavior (OR 1.3 95% CI 1.1-1.5) and substance use (OR 1.8, 95% CI 1.4-2.2) compared with nondepressed adolescents. Results for secondary outcomes showed a similar pattern, with higher delinquency (OR 3.2, 95% CI 1.8-5.6), self-harm (OR 4.4, 95% CI 1.3-14.4), and suicidal behavior (OR 6.6, 95% CI 2.3-18.9) among adolescents with depression compared with healthy adolescents.This study suggests that adolescents with depression in LMICs carry a double burden: depression and increased risk of engaging in risky behaviors. 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.