https://orcid.org/0009-0001-4272-1370
Figures
Abstract
Aims
Depression, a leading contributor to the global disease burden, exhibits alarming increases in incidence and prevalence, with pronounced disparities across regions and genders. This study provides the first comprehensive analysis of depression burden from 1990 to 2021, integrating the latest Global Burden of Disease (GBD) 2021 data to identify critical hotspots and policy-relevant trends.
Methods
Estimated global, regional, and national burden of disease for depression from 1990–2021 by extracting incidence, prevalence, and DALYS from the Global Burden of Disease(GBD) database 2021.
Results
From 1990 to 2021, the global incidence of depression surged by 15.6% (3,749–4,334 per 100,000), with Sub-Saharan Africa emerging as an unexpected epicenter. Uganda and The Gambia recorded the highest incidence rates globally (9,644 and 7,624 per 100,000, respectively), likely linked to civil instability and healthcare deficits. Women bore a disproportionate burden, with adolescent females (15–19 years) showing 64% higher incidence than males (5,584 vs. 3,401 per 100,000). High-income regions paradoxically exhibited steeper annual percentage increases (EAPC: 1.0 in North America), suggesting improved detection or escalating stressors.
Citation: Liu J, Ye Z, Cai Y, Li J, Dong Z, Zhang X, et al. (2025) Unmasking the rising global burden of depression: A 32-year GBD analysis of gender disparities and regional hotspots in Sub-Saharan Africa. PLoS One 20(7): e0326974. https://doi.org/10.1371/journal.pone.0326974
Editor: Pengpeng Ye, National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, CHINA
Received: February 26, 2025; Accepted: June 6, 2025; Published: July 31, 2025
Copyright: © 2025 Liu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its Supporting Information files.
Funding: This work was supported by the Shanghai Municipal Healthcare Commission Healthcare Program (202340155); Shanghai Pudong New District Clinical TCM Characteristic Discipline Construction Grant (YC-2023-0611); Shanghai Pudong New District Health System Leading Talent Training Program (PWRl2023-10); Shanghai Municipal Health Commission Traditional Chinese Medicine Research Project (2024BJ018); Discipline Leader, Pudong New District Health Committee (PWRD2022-20). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Depression, as a pervasive mood disorder, has become an important challenge in the field of global public health, and the increasing trend of its incidence and prevalence has attracted widespread attention. According to the World Health Organization, more than 264 million people worldwide suffer from depression, a number that has shown an upward trend over the past few decades [1]. Depression not only affects an individual’s mental health, but can also lead to a range of health problems, including cardiovascular disease, decreased cancer survival, increased suicide rates, and increased cognitive impairment in Alzheimer’s disease [2–4]. In addition, depression places a heavy financial burden on patients and their families, with an average annual direct cost of between $1000 and $2500 per patient [5]. As the global population grows and ages, the disease burden of depression is expected to continue to increase and is expected to be the leading cause of the global disease burden by 2030 [6].
Since the 90s of the 20th century, the incidence and prevalence of depression have increased globally. According to data from the GBD, the global age-standardized incidence of depression declined between 1990 and 2019, but increased in regions with high sociodemographic indices [7]. This phenomenon may be related to social competitive pressure, individualistic culture, and social acceptance of awareness and help-seeking behavior in areas with high SDI [8]. In addition, the incidence of depression varies significantly among ages, periods, and birth cohorts, and these differences may be influenced by a variety of factors, including sociodemographic factors, economic status, and education level [9].
Previous studies on the global burden of depression have been limited in their scope and depth, often focusing on specific time periods or regions and failing to thoroughly analyze long-term trends. Moreover, due to data constraints, these studies have had difficulty in disentangling the independent effects of age, period, and birth cohort on depression onset. To address these gaps and provide a more nuanced understanding of depression’s disease burden, this study leverages the 2021 GBD Study data. We conduct a comprehensive analysis of depression’s incidence, prevalence, and DALYS across global, regional, and national levels from 1990 to 2021, with a particular emphasis on gender and age differences. Unlike prior studies, our approach delves deeper into the intricate interplay of various factors influencing depression burden. By doing so, this study not only enriches the existing knowledge base but also offers valuable insights for developing more effective and targeted prevention and control strategies. It provides a unique perspective on the global distribution of depression burden, which is not fully captured in the GBD document alone. Specifically, our analysis reveals how the burden varies across different socio-demographic groups and geographical regions, shedding light on areas that require urgent attention and resource allocation. This enables policymakers and healthcare professionals to better identify high-risk populations and implement tailored interventions to mitigate the impact of depression on a global scale.
Methods
Data sources
This study is based on the GBD 2021 database, which provides detailed epidemiological data on 371 diseases and injuries in 204 countries and territories between 1990 and 2021. The GBD 2021 database aggregates data from numerous sources, including but not limited to, health surveys, medical records, and epidemiological studies conducted in each country. However, the exact sample size or source count for each regional estimate may vary due to differences in data availability and quality across regions.We use standardized epidemiological analysis methods to ensure global comparability of data. These data are freely available through the Global Health Data Exchange website [10], and detailed methods and models have been described in previous reports [11]. Specifically, we extracted data on depressive disorders, including incidence, prevalence, and disability-adjusted life years. Data were accessed and downloaded through the Global Health Data Exchange (GHDx) platform (http://ghdx.healthdata.org/gbd-results-tool).
Important definitions
The socio-demographic index is a comprehensive measure of the overall economic development of a society, taking into account the level of education, per capita income, and fertility rate [12]. SDI values range from 0 to 1, with higher values reflecting higher levels of social and economic development. Based on the SDI values of the GBD 2021 study, we categorized 204 countries into five SDI groups: High, High middle, Middle, Low middle, and Low. Uncertainty Interval (UI) is an important statistical tool calculated by multiple sampling and correlation matrix when GBD processes international data, taking into account the differences in methods and missing data. It reflects global differences in data collection and processing methods, as well as the reality that data quality is affected by a variety of factors, and is essential for assessing the reliability of data across countries and comparing the results of studies. Confidence intervals (CI) are statistically determined and used to estimate the possible range of population parameters, calculated based on sample data. In the present study, we obtained incidence and prevalence data from the GBD database and used the UI to identify uncertainties in these data to more accurately reflect the reliability of the findings.
Statistical analysis
Age-Standardized Incidence Rate (ASR) and Estimated Annual Percentage Change (EAPC): Used to quantify trends in the incidence of depression. ASR is the incidence after excluding age. The ASR for depression does not reflect the actual incidence of depression, but is only used to compare the incidence of depression in different countries, regions, or different historical periods in the same region for data comparison. If the age structure of the population in two regions is very different, comparing the incidence rates alone does not reveal whether the high incidence in a given region is due to differences in age composition or other contributing factors. Therefore, it is necessary to standardize the incidence according to age. The methods used to calculate ASR have been previously reported [13]. The Estimated Annual Percentage Change (EAPC) is a statistical measure that describes the average annual percentage change in a rate over a specified time period. A positive EAPC indicates an increasing trend, while a negative EAPC indicates a decreasing trend.R Studio (version 4.4.0) was used for statistical analysis. Statistical significance was defined as P < 0.05 for all bilateral P values.
Results
The burden of depression from a global perspective
The study included a total of 204 countries around the world to assess the incidence, prevalence, and DALYS of depression from 1990 to 2021. Studies have shown an upward trend in the incidence, prevalence, and DALYS of depression globally from 1990 to 2021 (Table 1). The incidence rate increased from 3,748.5 to 4,333.6 per 100,000 people, and the prevalence rate increased from 3,599.7 to 4,006.8 per 100,000 people.
Differences at the regional and national levels
African countries have higher rates of both incidence and prevalence of depression, with Uganda and the Gambia being particularly significant. Specifically, the incidence rate is about 9,644 cases per 100,000 people in Uganda and 7,624 cases in the Gambia (Fig 1A). In terms of prevalence, Uganda has about 7,770 cases and The Gambia has 7,222 cases (Fig 1B). In addition, Palestine has the highest DALYS for depression globally, with 1,357 cases per 100,000 people (Fig 1C).
Socio-economic and health resource allocation implications
The study showed that EAPC values were generally higher in high-income areas and lower in low-income areas (Fig 2). Among them, the high-income North America region had the highest rate of change in incidence (1.0) (Fig 2A), while the lowest in Central Asia (−1.0) (Fig 2B), the highest rate of change in prevalence in high-income Asia-Pacific (0.4) (Fig 2C), the lowest in South Asia (−0.4) (Fig 2D), the highest rate of change in DALYS rate in high-income Asia Pacific (0.6) (Fig 2E), and the lowest rate of change in Eastern Europe (−0.3) (Fig 2F).
Crowd analysis
The incidence of depression is generally higher in women than in men, especially during adolescence and early adulthood(S2 Table). The incidence of depression in women aged 15–19 was 5,583.94 per 100,000, compared with 3,400.62 per 100,000 for men in the same age group.
The global prevalence of depression among women aged 15–19 years in 2021 was 4,228.78 per 100,000, compared with 2,575.45 per 100,000 for men in the same age group(S3 Table). This gender difference is particularly significant in certain age groups, such as 6,014.01 per 100,000 in women and 3,962.54 per 100,000 in men in the 25–29 age group.(S4 Table) shows that DALYS are generally higher in women than in men in most age groups. In terms of age groups: DALYS are higher in adolescents and early adulthood (15–29 years).
The global prevalence of depression varies significantly between age groups and genders(Fig 3). The prevalence of depression is significantly higher in women than in men, particularly in adolescence, and this trend continues into early adulthood. In addition, the prevalence of depression decreases in the older population with age, but remains at a high level.
Regional gender differences
Globally, the incidence of depression in women (5,295.22 per 100,000 people) is significantly higher than that in men (3,366.27 per 100,000 people)(S5 Table). Especially in high-income North America, the incidence rate in females (8,587.86 per 100,000 population) is much higher than that in males (4,566.66 per 100,000 population). In addition, Eastern Europe, Central Asia and the Caribbean also show significant gender differences, with females all having a higher incidence than males.
Globally, the prevalence of depression in women (4,822.12 per 100,000 people) is higher than that in men (3,186.43 per 100,000 people)(S6 Table), and in high-income North America, the prevalence of depression in men is 3,853.58 per 100,000 people, and the prevalence rate in women is 6,964.76 per 100,000 people. In Eastern Europe: the prevalence of depression in men was 3,629.66 per 100,000 population and in women it was 4,766.92 per 100,000 population.
Globally, the rate of DALYS for depression (821.17 per 100,000 people) is significantly higher in women than in men (540.51 per 100,000 people) (S7 Table). In Western Europe, the DALYS rate for women (1,087.54 per 100,000 population) is much higher than that for men (630.85 per 100,000 population). In addition, Eastern Europe, South Asia and the Caribbean also showed significant gender differences, with women having higher rates of DALYS than men.
The incidence, prevalence, and DALYS of depression were higher in women than in men in most regions (Fig 4), which may reflect differences in socioeconomic status, cultural factors, and perceptions of mental health problems and coping strategies in different regions.
Regional time differences
The incidence of depression is highest in high-income North America, at 6,572 per 100,000 population, while in East Asia it is relatively low at 2,338 per 100,000 population(S8 Table). The prevalence of depression is highest in high-income North America, at 5,408 per 100,000 population, while in East Asia it is relatively low at 2,871 per 100,000 population (S9 Table).
Sub-Saharan Africa has the highest rate of DALYS for depression at 1137 per 100,000 people, while East Asia has a relatively low rate of DALYS at 430 per 100,000 people(S10 Table).
Fig 5 shows that there are significant differences in the incidence, prevalence and disability-adjusted life years of depression in different regions.
Incidence is higher in High-income Asia Pacific and High-income North America, while lower in Central Asia and Central Sub-Saharan Africa(S11 Table and S6 FigA). The prevalence of depression in East Asia decreased from 3,059.66 per 100,000 population in 1990–2,870.61 per 100,000 population in 2021(S12 Table and S6 FigB).
From 1990 to 2021, the global rate of DALYs due to depression varied(S13 Table and S6 FigC). The global DALYs rate changed from 601 in 1990–681 in 2021. The DALYS rate in high-income North America increased from 641 in 1990–983 in 2021. In contrast, the DALYS rate in the East Asia Pacific region changed from 471 in 1990–430 in 2021, showing a downward trend.
Discussion
Based on data from the 2021 Global Burden of Disease Study, this study provides a comprehensive analysis of global, regional, and national depression incidence, prevalence, and disability-adjusted life years between 1990 and 2021. We found that the incidence, prevalence, and disability-adjusted life years of depression increased globally over the past three decades. This finding is consistent with previous findings and further confirms the importance of depression as a global public health problem [2]. However, our results reveal significant regional and gender disparities, especially in high-income regions and among women, with a more significant increase in depression, providing deeper insights into the global distribution of depression [14].
The findings reveal unusually high values in the incidence and prevalence of depression in African countries. A striking aspect of our results is the pronounced regional disparities in depression burden, with Sub-Saharan Africa emerging as a critical area of concern. ongoing social conflict, economic hardship, and lack of medical resources could potentially be key factors contributing to the increased burden of depression in these countries [15], Uganda’s incidence (9,644/100,000) may be associated with prolonged civil conflict [16], where trauma and displacement exacerbate depressive symptoms. Moreover, the severe shortage of mental health resources in countries like the Gambia, where a mere two psychiatrists serve a population of 2.5 million [17], highlights the dire need for improved mental health infrastructure. These factors, combined with the challenges posed by infectious diseases and cultural stigma surrounding mental illness, create a complex web of issues that contribute to the region’s elevated depression burden.
The influence of socio-economic status and medical resource allocation on depression is another key highlight of this study. We found that high-income areas usually show higher EAPC values, which may reflect better access to mental health services and higher diagnosis rates. However, this association also hints at possible health inequalities, that is, areas with less resources may fail to adequately identify and treat depression [14]. This finding emphasizes the importance of fair distribution of medical resources on a global scale, especially in low- and middle-income countries. In addition, this also prompts the need to raise mental health awareness and improve mental health services in primary health care centers.
In addition to the socio-economic and healthcare resource factors, cultural factors and differences in perceptions of mental health may also influence the reporting and diagnosis rate of depression. In their study, Kirmayer et al. noted that the experience and manifestation of depression differ significantly between cultures, suggesting that cultural factors play an important role in the recognition and understanding of depression [18]. They emphasize that certain symptoms, such as loneliness, anger, crying, and diffuse pain, are not included in the diagnostic and statistical manual of mental disorders, fifth edition, diagnostic criteria for DSM-5, although prevalent in multiple cultures. The cultural relevance and presentation of these symptoms may vary from region to region, thus influencing the reporting and diagnosis of depression [18]. In addition, Kirmayer et al. discussed the “looping effects”, in which people perceive and act on the world through our constructions, resulting in the phenomena we are trying to describe, which may alter the individual’s experience and physiological state, further influencing the reporting and diagnosis of depression [18].
Gender differences are another notable finding of this study. “The 64% female predominance in adolescents mirrors estrogen’s neuro-modulatory effects [19]and societal pressures. Conversely, higher male underreporting—linked to stigma [20]—may mask true disparities.” In general, women exhibit a higher prevalence of depression than men across incidence, prevalence, and DALYs metrics, especially during adolescence and early adulthood. This phenomenon may be related to hormonal changes, social role expectations, and gender-specific life stressors [21,20]. Additionally, women are more likely to seek mental health services, which can lead to higher reporting rates. The cumulative effect of these factors may lead to gender differences in depression risk at different life stages, and in view of the significance of gender differences, we can use biopsychosocial models to fully understand the pathogenesis of depression in different genders. This model considers the interaction of biological, psychological, and sociocultural factors and how these factors work together to influence the formation of gender differences in depression. According to a review article in Progress in Neurobiology, gender differences are present in multiple aspects of depression, including epidemiology, symptomatology, treatment, and pathophysiology [19].
There are several limitations to this study: First, the study used incidence, prevalence, and disability-adjusted life years to assess the burden of depression, but these measures may not fully reflect the actual impact of depression on patients’ quality of life. Secondly, the study is mainly based on group data, and fails to deeply analyze the influencing factors at the individual level, such as personal experience and family background, which may have an important impact on the occurrence and development of depression. Finally, depression is often comorbid with other diseases, such as cardiovascular disease, diabetes, etc., which may have an impact on the disease burden of depression, but this has not been analysed in detail.
Additionally, reporting biases across regions are a concern. In areas with limited mental health infrastructure, such as The Gambia (only 2 psychiatrists for 2.5 million people), underdiagnosis of depression is likely, possibly underestimating the true depression burden. Cultural factors also play a significant role in reporting depressive symptoms. In some cultures, certain depression symptoms may be expressed or perceived differently, and may not align with the GBD study’s diagnostic criteria. This could influence reported depression rates and introduce data biases.
Conclusion
This study, combined with the Global Burden of Disease database, found that the burden of depression has risen, especially in parts of Africa, such as Uganda and the Gambia, and among women. These disparities may be related to access to socioeconomic, cultural, and mental health services. The study highlights the need for strategies for the prevention, identification, and treatment of depression globally, especially in low- and middle-income countries, and the need to consider gender-specific factors in public health policies. Future research needs to adopt a multidisciplinary approach to deeply explore the pathogenesis of depression and provide scientific support for the management of depression worldwide.
Supporting information
S2 Table. Global incidence of depression (by age, sex).
https://doi.org/10.1371/journal.pone.0326974.s001
(DOCX)
S3 Table. Global prevalence of depression (by age, sex).
https://doi.org/10.1371/journal.pone.0326974.s002
(DOCX)
S4 Table. Global DALYs of depression (by age, sex).
https://doi.org/10.1371/journal.pone.0326974.s003
(DOCX)
S5 Table. Global and regional gender-age standardized depression incidence data (2021).
https://doi.org/10.1371/journal.pone.0326974.s004
(DOCX)
S6 Table. Global and regional gender-age standardized depression prevalence data (2021).
https://doi.org/10.1371/journal.pone.0326974.s005
(DOCX)
S7 Table. Global and regional gender-age standardized depression DALYsdata (2021).
https://doi.org/10.1371/journal.pone.0326974.s006
(DOCX)
S8 Table. Global and Regional Age-Standardized Depression Incidence Temporal Trend Data (2021).
https://doi.org/10.1371/journal.pone.0326974.s007
(DOCX)
S9 Table. Global and Regional Age-Standardized Depression Prevalence Temporal Trend Data (2021).
https://doi.org/10.1371/journal.pone.0326974.s008
(DOCX)
S10 Table. Global and Regional Age-Standardized Depression DALYs Temporal Trend Data (2021).
https://doi.org/10.1371/journal.pone.0326974.s009
(DOCX)
S11 Table. Global and Regional Time Series Data on Depression Incidence (1990–2021).
https://doi.org/10.1371/journal.pone.0326974.s010
(DOCX)
S12 Table. Global and Regional Time Series Data on Depression Prevalence (1990–2021).
https://doi.org/10.1371/journal.pone.0326974.s011
(DOCX)
S13 Table. Global and Regional Time Series Data on Depression DALYs (1990–2021).
https://doi.org/10.1371/journal.pone.0326974.s012
(DOCX)
S6 Fig. The relationship between global and regional health indicators and socio-demographic indicators: a comparative analysis of morbidity, Prevalence and DALYs rates.
https://doi.org/10.1371/journal.pone.0326974.s013
(TIF)
Acknowledgments
We would also like to thank the countless individuals who have contributed to the Global Burden of Disease Study 2021 in various capacities.
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