Journal Pre-proof

Changes in the global burden of depression from 1990 to 2017: Findings from the
Global Burden of Disease study

Qingqing Liu, Hairong He, Jin Yang, Xiaojie Feng, Fanfan Zhao, Jun Lyu

PII: S0022-3956(19)30738-1
DOI: https://doi.org/10.1016/j.jpsychires.2019.08.002
Reference: PIAT 3715

To appear in: Journal of Psychiatric Research

Received Date: 22 June 2019

Revised Date: 3 August 2019
Accepted Date: 8 August 2019

Please cite this article as: Liu Q, He H, Yang J, Feng X, Zhao F, Lyu J, Changes in the global burden of
depression from 1990 to 2017: Findings from the Global Burden of Disease study, Journal of Psychiatric
Research (2019), doi: https://doi.org/10.1016/j.jpsychires.2019.08.002.

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© 2019 Published by Elsevier Ltd.

Changes in the global burden of depression from 1990 to
2017: findings from the Global Burden of Disease study
1,2a 1a
Qingqing Liu , Hairong He , Jin Yang1,2, Xiaojie Feng1,2, Fanfan Zhao1,2 , Jun Lyu1,2,

1
Clinical Research Center, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China;
2
School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, China;
a
: These authors contributed equally to this work.

*Address correspondence to Dr. Jun Lyu at Clinical Research Center, The First Affiliated Hospital of Xi’an
Jiaotong University, Xi’an 710061, People’s Republic of China.
Tel: 86-29-85323614
E-mail: lujun2006@xjtu.edu.cn

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit

sectors.

Compliance with ethical standards

Disclosure The author reports no conflicts of interest in this work.

Abstract
Objective: Depression is the most common mental illness worldwide. It has become
an important public health problem. This study aimed to determine the global burden
of depression and how it has changed between 1990 and 2017.
Methods: We used information on depression obtained by the Global Burden of
Disease (GBD) study from 1990 to 2017. The age-standardized incidence rate (ASR)
and estimated annual percentage change (EAPC) were used to assess the global
burden of depression.
Results: The number of incident cases of depression worldwide increased from 172
million in 1990 to 25,8 million in 2017, representing an increase of 49.86%. The ASR
of depression varied widely between the 195 analyzed countries and regions in 2017,
being highest in Lesotho (6.59 per 1000) and lowest in Myanmar (1.28 per 1000). The
ASR increased the most between 1990 and 2017 in Belgium (EAPC = 0.88, 95%

1
confidence interval [CI] = 0.78 to 0.97), and decreased the most in Cuba (EAPC = –
1.26, 95% CI = –1.36 to –1.14). The ASR increased in regions with a high
sociodemographic index, such as high-income North America (EAPC = 0.41, 95% CI
= 0.31 to 0.51), and decreased significantly in South Asia (EAPC = –0.63, 95% CI = –
0.85 to –0.41). The proportions of the population with major depressive disorder
and dysthymia were essentially stable both globally and in various countries, with a
much larger proportion having major depressive disorder.
Conclusion: Depression remains a major public health issue, and governments should
support the research necessary to develop better prevention and treatment
interventions.

Key words Depression; the Global Burden of Disease; dysthymia; major

depressive disorder

2
Introduction
Depression is a common mental health disorder that can affect both the mental and
physical health. The main symptoms of depression are a lack of interest in usual life
activities, insomnia, inability to enjoy life, and even suicidal thoughts(Cui, 2015).
Depression is nowadays a common chronic disease in most societies worldwide that
can impair normal functioning, cause depressive thoughts, and adversely affect the
quality of life. In addition, patients with major depressive disorder have increased
risks of developing cardiovascular disease and receiving poor treatment, and
increased morbidity and mortality(Luo et al., 2018; Seligman and Nemeroff, 2015). It
is estimated that more than 300 million people in the world suffer from depression,
which is listed by the World Health Organization (WHO) as the single largest factor
contributing to global disability(Smith, 2014). One of the most-worrying aspects is
that adolescents with severe depression are 30 times more likely to commit
suicide(Stringaris, 2017). However, while depression is now one of the most
important global health problems, its complex pathogenesis remains poorly
understood, although it is known that cultural, psychological, and biological factors
contributed to depression(Gross, 2014; Menard et al., 2016).
The Global Burden of Disease (GBD) study provides specific data on multiple
diseases in 195 countries and regions around the world, including information about
depression. The GBD database represents a wealth of information for understanding
the incidence of depression worldwide, and it divides depression into two major
categories: dysthymia and major depressive disorder. In this study we used the data on
depression in the GBD database from 1990 to 2017 to analyze the temporal trends in
the incidence of depression. Our findings will help to improve the understanding of
the burden of depression worldwide and in developing effective prevention strategies.

Methods
Data source
The data utilized in this study are available on the Global Health website
(http://ghdx.healthdata.org). Each step used in this study to analyze the GBD database
3
was consistent with the Guidelines for Accurate and Transparent Health Estimates
Reporting, which has been described in detail previously(2016a; 2016b; 2016c;
Stevens et al., 2016). The GBD database contains data on different diseases in 195
countries and regions, and we extracted data on depression from 1990 to 2017. In
order to describe the prevalence of depression from multiple angles, we divided the
world into five regions according to their sociodemographic index (SDI): low,
low-middle, middle, high-middle, and high SDI. These 195 countries and regions
were geographically divided into 21 areas, such as Andean Latin America, Central
Europe, and Southeast Asia. This study used these data to describe the prevalence of
dysthymia and major depressive disorder according to different SDI regions and
geographical locations. In GBD, depression is divided into two categories: dysthymia
and major depressive disorder. The study also described the prevalence of these two
types of depression in different countries and regions, different SDI regions, and
geographical locations.
Statistical analysis
The age-standardized incidence rate (ASR) and estimated annual percentage
change (EAPC) were used to quantify the incidence trends of depression(Hankey et
al., 2000). The age-standardized morbidity is the morbidity after excluding the effects
of age. The ASR of depression does not reflect the actual incidence of depression, but
is only used to compare the incidence of depression in different countries, different
regions, or different historical periods in the same region, so as to facilitate data
comparisons. If the age structures of the populations in two regions are very different,
comparing the incidence rates alone will not reveal whether a high incidence in a
certain region is caused by the difference in the age compositions or other influencing
factors. It is therefore necessary to standardize the incidence rate according to age.
The method used to calculate ASR has been reported previously(Liu et al., 2019).
EAPC is a summary and widely used measure of the ASR trend over a specific time
interval. A regression line was fitted to the natural logarithm of the ASR values; that is,
y = α + βx + ɛ, where y = ln(ASR) and x  = calendar year. The EAPC was calculated as
100 × (exp(β) − 1), and its 95% confidence interval (CI) was obtained from a linear
4
regression model(Liu et al., 2019). The ASR is considered to be (1) decreasing when
the EAPC and the upper boundary of its 95% CI are both ≤0, (2) increasing when the
EAPC and the lower boundary of its 95% CI are ≥0, and (3) stable in all other cases.
In addition, the ASR values for the two types of depression were analyzed by
hierarchical cluster analysis, and the countries and regions were divided into four
states: significantly increased, slightly increased, remaining stable or slightly
decreased, and significantly decreased. All statistical analyses in this study were
performed using R software.

Results
Global burden of depression
The ASR of depression in the 195 analyzed countries and regions varied widely
in 2017 (Figure 1A), being highest in Lesotho (6.59 per 1000), followed by Morocco
(6.31 per 1000) and Greenland (6.26 per 1000), and lowest in Myanmar (1.28 per
1000), followed by Indonesia (1.79 per 1000) and the Philippines (1.97 per 1000).
The number of incident cases of depression worldwide increased from 172 million in
1990 to 25,8 milion in 2017, representing an increase of 49.86%. The increase was
largest in Qatar (559.33%), followed by the United Arab Emirates (511.76%) and
Equatorial Guinea (221.87%) (Figure 1B). The number of incident cases of
depression decreased from 1990 to 2017 in 18 countries, by the most in Latvia (–
30.99%), followed by Bosnia and Herzegovina (–25.75%) and Georgia (–23.98%).
Figure 1A, B, C

The increase in ASR across the 195 countries and regions was largest in Belgium
(EAPC = 0.88, 95% CI = 0.78 to 0.97), followed by Guyana (EAPC = 0.53, 95% CI =
0.42 to 0.64) and South Korea (EAPC = 0.52, 95% CI = 0.41 to 0.64) (Figure 1C).
The decrease in ASR was largest in Cuba (EAPC = –1.26, 95% CI = –1.36 to –1.14),
followed by Denmark (EAPC = –1.21, 95% CI = –1.37 to –1.04) and Estonia (EAPC
= –1.06, 95% CI = –1.18 to –0.94).
Cluster analysis (Figure S1) classified the ASR as (1) significantly increased in 29
countries, including Armenia, Belgium, and Iran; (2) slightly increased in 132

5
countries, including Afghanistan, Albania, and Australia; (3) remaining stable or
slightly decreased in 25 countries, including Austria, Bahrain, and Bermuda; and (4)
significant decreased in 9 countries, including Cuba, Bosnia and Herzegovina, and
Denmark.
The number of people with depression increased in all five SDI regions between
1990 and 2017 (Figure 2). However, the ASR decreased in the high-middle-SDI,
low-SDI, low-middle-SDI, and middle-SDI regions, only increasing in the high-SDI
region (Table 1). The number of people with depression increased in all geographical
regions (Figure 3), by the most in Central sub-Saharan Africa (124.56%), followed by
Western sub-Saharan Africa (124.42%) and Oceania (107.19%). The ASR increased
significantly in high-income North America (EAPC = 0.41, 95% CI = 0.31 to 0.51)
and decreased significantly in South Asia (EAPC = –0.63, 95% CI = –0.85 to–0.41)
(Figure 4, Table 1).
Figure 4 shows the proportions of cases of dysthymia and major depressive
disorder worldwide in 1990 and 2017. The proportion of the population with the two
types of depression remained essentially stable both globally and regionally, with a
much larger proportion having major depressive disorder.
Table 1, Figure 2, Figure 3

Global burden of major depressive disorder

The majority (93.7%) of patients with depression in 2017 had major depressive
disorder (Figure 5). The ASR of major depressive disorder varied widely among the
195 countries and regions in 2017, being highest in Lesotho (6.41 per 1000), followed
by Morocco (6.13 per 1000) and Greenland (6.01 per 1000) (Figure S2), and lowest in
Myanmar (1.06 per 1000), Indonesia (1.57 per 1000), and the Philippines (1.75 per
1000). The number of incident cases of major depressive disorder worldwide
increased from 162 million in 1990 to 241 million in 2017, representing an increase of
49.29%. The increase was largest in Qatar (557.67%), followed by the United Arab
Emirates (509.93%) and Equatorial Guinea (221.51%) (Figure S3, Table S3). The
number of incident cases decreased from 1990 to 2017 in 20 countries, by the most in
6
Latvia (–31.49%), followed by Bosnia and Herzegovina (–26.65%) and Georgia (–
23.69%).
The increase in ASR across the 195 countries and regions was largest in Belgium
(EAPC = 0.93, 95% CI = 0.83 to 1.02), followed by South Korea (EAPC = 0.57, 95%
CI = 0.45 to 0.69) and Guyana (EAPC = 0.55, 95% CI = 0.44 to 0.66) (Figure S4).
The decrease in the ASR was largest in Cuba (EAPC = –1.31, 95% CI = –1.42 to –
1.19), followed by Denmark (EAPC = –1.29, 95% CI = –1.47 to –1.11) and Estonia
(EAPC = –1.12, 95% CI = –1.24 to –0.99).
The number of cases of major depressive disorder in the five SDI regions increased
between 1990 and 2017. However, the ASR decreased in the high-middle-SDI,
low-SDI, low-middle-SDI, and middle-SDI regions, only increasing in the high-SDI
region (Figure 2, Table S1). The number of cases of major depressive disorder
increased in all geographical regions (Figure 3), by the most in Central sub-Saharan
Africa (124.33%), followed by Western sub-Saharan Africa (124.11%) and Oceania
(106.85%). The ASR increased significantly in high-income North America (EAPC =
0.46, 95% CI = 0.35 to 0.56) and decreased significantly in South Asia (EAPC = –
0.67, 95% CI = –0.90 to –0.43) (Figure 4, Table 1).
Figure 4, Figure 5

Global burden of dysthymia

Only 6.3% of the patients with depression in 2017 had dysthymia in 2017
(Figure 5). The ASR of dysthymia varied widely among the 195 countries and regions
in 2017, being highest in the United States (0.26 per 1000), followed by Canada (0.25
per 1000) and Greenland (0.25 per 1000) (Figure S5), and lowest in Colombia (0.13
per 1000), followed by Romania (0.15 per 1000) and Panama (0.15 per 1000). The
number of incident cases of dysthymia worldwide increased from 10 million in 1990
to 16 million in 2017, representing an increase of 58.98%. The increase was largest in
Qatar (601.91%), followed by the United Arab Emirates (547.94%) and Bahrain
(250.72%) (Figure S6, Table S5). The number of incident cases decreased from 1990
to 2017 in 11 countries, by the most in Georgia (–27.65%), followed by Latvia (–
22.52%) and Lithuania (–15.44%).
7
 The increase in ASR across the 195 countries and regions was largest in Iran
(EAPC = 0.12, 95% CI = 0.06 to 0.21), followed by India (EAPC = 0.11, 95% CI =
0.09 to 0.13) and Portugal (EAPC = 0.11, 95% CI = 0.05 to 0.16) (Figure S7). The
decrease in ASR was largest in the United States (EAPC = –0.33, 95% CI = –0.43 to –
0.24), followed by Colombia (EAPC = –0.21, 95% CI = –0.25 to–0.16) and Singapore
(EAPC = –0.21, 95% CI = –0.31 to –0.09).
The number of dysthymia cases in the five SDI regions increased between 1990
and 2017. However, the ASR only increased in the high-middle-SDI, low-SDI, and
low-middle-SDI regions, and decreased in the high-SDI and middle-SDI regions
(Figure 2, Table S1). The number of dysthymia cases increased in all geographical
regions (Figure 3), by the most in Western sub-Saharan Africa (130.23%), followed
by Central sub-Saharan Africa (130.04%) and Eastern sub-Saharan Africa (117.02%).
The ASR increased significantly in South Asia (EAPC = 0.09, 95% CI = 0.07 to 0.11)
and decreased significantly in high-income North America (EAPC = –0.31, 95% CI =
–0.39 to –0.22) (Figure 5, Table 1).

Discussion
Depression is a major public health problem and a major cause of disability(Ferrari
et al., 2013). This study used data published in the GBD database to analyze the
trends in depression from 1990 to 2017 and the global burden of depression. The
results of this study can be used by governments in all regions to develop appropriate
preventive measures for depression.
This study found that the number of incident cases of depression worldwide
increased by 49.86% from 1990 to 2017. The ASR was highest in Lesotho, which is a
poor landlocked country surrounded by South Africa that has the third highest rate of
HIV infection in the world, the highest rate of HIV transmission among the
high-prevalence countries of southern Africa, and the lowest coverage of antiretroviral
treatment(Cerutti et al., 2016). People diagnosed with HIV/AIDS often face social
stigma and restrictions in employment and marriage, which in some cases leads to
divorce and family exclusion(Ironson et al., 2017). People with HIV may experience

8
depression for many reasons, such as over concern about disease progression, pain,
and death(Junqueira et al., 2008). These characteristics of the situation in Lesotho
mean that preventing AIDS could be a key measure to control depression.
The ASR increased the most in Belgium, followed by Guyana and South Korea.
More research is needed to understand the causes of increased ASR in depression in
these countries. The country with the largest reductions in ASR was Cuba, followed
by Denmark and Estonia. The ASR increased significantly in the high-SDI region and
high-income North America (EAPC = 0.41, 95% CI = 0.31 to 0.51). The rapid
increases in the ASR of depression in these regions could be due to them having high
levels of economic development, education, and social pressure. Studies have found
that education can affect cognitive ability. It can affect depression in individuals and
even in spouses (Lee, 2011). Social stress is also a recognized risk factor for
depression(Smith, 2014).
Our findings show that the proportions of both types of depression were essentially
stable both globally and regionally, with a large proportion of patients having major
depressive disorder. As the most common cause of disability affecting nearly 16% of
the global population(Kessler et al., 2003), major depressive disorder is attracting
increasing attention. A WHO report predicted that major depressive disorder will
become the leading cause of disability in the world by 2030(Yang et al., 2015), and
stated that controlling major depressive disorder is the best way to address depression.
Regarding the ASR of dysthymia, although this has decreased the most in the United
States, that country still had the highest ASR in 2017. This shows that the United
States should pay more attention to this problem and continue to take measures aimed
at controlling dysthymia. The ASR of dysthymia decreased the most in the high-SDI
region and high-income North America, while the ASR of major depressive disorder
increased the most in these areas. This might be because some of the patients with
dysthymia in these areas progressed to major depressive disorder.
This study identified that there are especially high rates of depression in some
countries and regions, indicating the importance of identifying the underlying reasons.
Although the pathogenesis of depression is unknown, some studies have identified
9
risk factors for depression. Depressed people have a genetic predisposition, with the
risk of depression being significantly higher in relatives of depressed
people—especially their first-degree relatives—than in the general
population(Mullins and Lewis, 2017). Research has shown that age and gender are
also linked to depression, with women more likely to suffer from depression than men,
and older people more likely to suffer from depression as a result of more underlying
illnesses (Faravelli et al., 2013; Zhao et al., 2012). In addition to genetic and
psychological factors, studies have found that unhealthy lifestyles such as smoking
and alcohol consumption increase the risk of depression(Gravely-Witte et al., 2009;
Pavkovic et al., 2018). In addition, insomnia reportedly increases the risks of
depression and anxiety(Li et al., 2016). Numerous studies have shown that certain
diseases are related to the occurrence of depression. Depression is one of the most
common neuropsychiatric consequences of stroke, affecting about one-third of stroke
patients(Hackett et al., 2005). The prevalence of depressive symptoms in cancer
patients exceeds that in the general population, and depression is associated with a
poor prognosis in cancer patients(Sotelo et al., 2014). It has been found that children
and adolescents with enterovirus infection are susceptible to secondary
depression(Liao et al., 2017). The risk of depression is also higher in AIDS patients
than in the general population(Elbadawi and Mirghani, 2017).
The governments of countries with high rates of depression need to focus on
supporting relevant research to identify the underlying causes and take measures to
actively control the occurrence of depression. Healthy lifestyles such as increasing the
amount of physical exercise and giving up smoking and drinking should be advocated.
Patients with stroke, cancer, AIDS, and other diseases should be followed up and
provided with appropriate medications to prevent the occurrence of depression.
Medication and psychological interventions should be applied to people who are
already suffering from depression in order to prevent suicidal behavior.
This study has performed the most comprehensive assessment yet of the burden
of depression. However, it was also subject to some limitations. Firstly, the analyzed
data were obtained from the GBD database, in which depressive disorder is classified
10
into major depressive disorder and dysthymia, and so we were only able to analyze
the global burden of depression according to this classification method without further
subdivision. Secondly, only the global disease burden of depression was analyzed, and
the risk factors of depression in different countries and regions were not addressed.
Future studies are needed to focus on this issue in order to guide the development and
implementation of specific policies for controlling depression in different countries
and regions.

Conclusion
Depression affects the mental and physical health of patients and, as the most
common mental illness, has become an important public health problem. The findings
of this study on the global burden of depression from 1990 to 2017 will help
governments around the world to understand their own burdens of depression, and to
formulate and implement measures for the prevention and early treatment of
depression.

11
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13
Table 1. The incident cases and age-standardized incidence of depression in 1990 and 2017,
and its temporal trends from 1990 to 2017.
Characteristics 1990 2017 1990-2017
Incident cases ASR per 1000 Incident cases ASR per 1000 EAPC
No.×106(95%UI) No.(95%UI) No.×106(95%UI) No.(95%UI) No.(95%UI)
Global 172.27 ( 157.81 - 3.43 ( 3.16 - 258.16 ( 238.28 - 3.25 ( 3 - 3.54 ) -0.26 ( -0.31 -
189.31 ) 3.77 ) 281.67 ) -0.22 )
Sex
Male 65.1 ( 59.58 - 2.6 ( 2.4 - 99.87 ( 92.07 - 2.54 ( 2.34 - -0.15 ( -0.2 -
71.43 ) 2.85 ) 108.9 ) 2.76 ) -0.1 )
Female 107.16 ( 98.23 - 4.25 ( 3.91 - 158.29 ( 146.19 - 3.95 ( 3.64 - -0.33 ( -0.38 -
117.69 ) 4.66 ) 172.75 ) 4.31 ) -0.29 )
Etiology
Depressive 172.27 ( 157.81 - 3.43 ( 3.16 - 258.16 ( 238.28 - 3.25 ( 3 - 3.54 ) -0.26 ( -0.31 -
disorders 189.31 ) 3.77 ) 281.67 ) -0.22 )
Major depressive 162.03 ( 147.45 - 3.23 ( 2.96 - 241.89 ( 222.03 - 3.04 ( 2.8 - 0.01 ( -0.01 -
disorder 178.81 ) 3.55 ) 265.57 ) 3.34 ) 0.02 )
Dythymia 10.23 ( 8.97 - 0.2 ( 0.18 - 16.27 ( 14.24 - 0.2 ( 0.18 - -0.28 ( -0.33 -
11.61 ) 0.23 ) 18.42 ) 0.23 ) -0.23 )
Socio-demographic index
High SDI 37.08 ( 34.51 - 3.51 ( 3.26 - 45.18 ( 42.01 - 3.57 ( 3.3 - 0.12 ( 0.1 -
40.25 ) 3.81 ) 48.88 ) 3.89 ) 0.15 )
High-middle SDI 37.79 ( 34.58 - 3.47 ( 3.18 - 51.88 ( 47.53 - 3.23 ( 2.97 - -0.29 ( -0.3 -
41.53 ) 3.79 ) 56.74 ) 3.53 ) -0.27 )
Low SDI 21.04 ( 19.05 - 4.03 ( 3.68 - 40.01 ( 36.52 - 3.82 ( 3.5 - -0.32 ( -0.44 -
23.28 ) 4.44 ) 44.16 ) 4.18 ) -0.2 )
Low-middle SDI 33.66 ( 30.64 - 3.99 ( 3.65 - 57.55 ( 52.85 - 3.73 ( 3.42 - -0.39 ( -0.52 -
37.11 ) 4.38 ) 63.2 ) 4.08 ) -0.25 )
Middle SDI 41.99 ( 38.19 - 3.01 ( 2.76 - 62.61 ( 57.55 - 2.78 ( 2.56 - -0.36 ( -0.4 -
46.41 ) 3.3 ) 68.3 ) 3.02 ) -0.33 )
Region
Andean Latin 0.84 ( 0.76 - 0.93 ) 2.62 ( 2.41 - 1.53 ( 1.4 - 1.67 ) 2.56 ( 2.34 - -0.18 ( -0.2 -
America 2.89 ) 2.79 ) -0.15 )
Australasia 0.94 ( 0.86 - 1.03 ) 4.38 ( 4 - 1.27 ( 1.17 - 1.4 ) 4.31 ( 3.93 - -0.07 ( -0.16 -
4.79 ) 4.77 ) 0.02 )
Caribbean 1.18 ( 1.08 - 1.3 ) 3.58 ( 3.29 - 1.57 ( 1.43 - 1.71 ) 3.2 ( 2.93 - -0.5 ( -0.54 -
3.9 ) 3.49 ) -0.46 )
Central Asia 1.75 ( 1.61 - 1.93 ) 2.91 ( 2.68 - 2.47 ( 2.27 - 2.68 ) 2.81 ( 2.59 - -0.16 ( -0.19 -
3.18 ) 3.05 ) -0.13 )
Central Europe 3.45 ( 3.19 - 3.76 ) 2.54 ( 2.34 - 3.39 ( 3.13 - 3.67 ) 2.31 ( 2.13 - -0.45 ( -0.49 -
2.77 ) 2.51 ) -0.41 )
Central Latin 3.66 ( 3.31 - 4.04 ) 2.69 ( 2.46 - 7.04 ( 6.46 - 7.7 ) 2.74 ( 2.52 - 3 ) 0 ( -0.08 - 0.08 )
America 2.96 )
Central 1.92 ( 1.72 - 2.14 ) 4.64 ( 4.21 - 4.3 ( 3.88 - 4.8 ) 4.52 ( 4.13 - -0.12 ( -0.14 -

14
Sub-Saharan 5.11 ) 4.98 ) -0.11 )
Africa
East Asia 37.65 ( 34.37 - 3.08 ( 2.83 - 48.27 ( 44.11 - 2.62 ( 2.41 - -0.58 ( -0.66 -
41.59 ) 3.38 ) 52.77 ) 2.85 ) -0.5 )
Eastern Europe 9.6 ( 8.67 - 10.71 ) 3.78 ( 3.42 - 9.21 ( 8.29 - 3.54 ( 3.2 - -0.43 ( -0.53 -
4.21 ) 10.27 ) 3.94 ) -0.33 )
Eastern 5.91 ( 5.32 - 6.57 ) 4.43 ( 4.03 - 12.06 ( 10.91 - 4.19 ( 3.84 - -0.26 ( -0.31 -
Sub-Saharan 4.87 ) 13.35 ) 4.59 ) -0.21 )
Africa
High-income Asia 5.4 ( 4.99 - 5.88 ) 2.84 ( 2.62 - 6.73 ( 6.25 - 7.29 ) 3.14 ( 2.9 - 0.38 ( 0.29 -
Pacific 3.09 ) 3.42 ) 0.47 )
High-income 11.91 ( 10.93 - 4 ( 3.66 - 16.16 ( 14.99 - 4.32 ( 3.98 - 0.41 ( 0.31 -
North America 13.1 ) 4.41 ) 17.48 ) 4.7 ) 0.51 )
North Africa and 12.54 ( 11.32 - 4.4 ( 4 - 4.86 ) 25.74 ( 23.36 - 4.36 ( 3.98 - -0.07 ( -0.1 -
Middle East 13.93 ) 28.58 ) 4.81 ) -0.03 )
Oceania 0.14 ( 0.13 - 0.16 ) 2.6 ( 2.37 - 0.29 ( 0.26 - 0.33 ) 2.61 ( 2.39 - -0.01 ( -0.03 -
2.87 ) 2.88 ) 0.02 )
South Asia 36.1 ( 32.87 - 4.05 ( 3.7 - 61.19 ( 56.13 - 3.66 ( 3.36 - 4 ) -0.63 ( -0.85 -
40.03 ) 4.47 ) 67.06 ) -0.41 )
Southeast Asia 8.6 ( 7.78 - 9.53 ) 2.09 ( 1.9 - 13.58 ( 12.43 - 2 ( 1.84 - 2.19 ) -0.2 ( -0.22 -
2.29 ) 14.87 ) -0.17 )
Southern Latin 1.71 ( 1.57 - 1.87 ) 3.48 ( 3.21 - 2.34 ( 2.13 - 2.57 ) 3.38 ( 3.08 - -0.17 ( -0.2 -
America 3.81 ) 3.73 ) -0.14 )
Southern 1.71 ( 1.55 - 1.9 ) 3.97 ( 3.63 - 2.83 ( 2.59 - 3.12 ) 3.91 ( 3.6 - -0.06 ( -0.1 -
Sub-Saharan 4.36 ) 4.28 ) -0.03 )
Africa
Tropical Latin 5.29 ( 4.81 - 5.86 ) 3.85 ( 3.53 - 8.03 ( 7.42 - 8.72 ) 3.44 ( 3.18 - -0.47 ( -0.95 -
America 4.22 ) 3.75 ) 0.01 )
Western Europe 16.34 ( 15.28 - 3.78 ( 3.52 - 17.53 ( 16.19 - 19 ) 3.51 ( 3.23 - -0.23 ( -0.28 -
17.6 ) 4.08 ) 3.84 ) -0.19 )
Western 5.62 ( 5.11 - 6.22 ) 4.05 ( 3.69 - 12.62 ( 11.45 - 4.02 ( 3.68 - 0.11 ( 0.04 -
Sub-Saharan 4.45 ) 13.97 ) 4.4 ) 0.18 )
Africa

15
 Figure legends
Figure 1. The global disease burden of depression for both sexes in 195 countries and
territories. (A) The ASR of depression in 2017; (B) The relative change in incident
cases of depression between 1990 and 2017; (C) The EAPC of depression ASR from
1990 to 2017. ASR, age-standardized rate; EAPC, estimated annual percentage
change.
Figure 2. The depression cases caused by different types, by SDI regions, from 1990
to 2017. SDI, socio-demographic index.
Figure 3. The incident cases of depression at a regional level. The left column in each
group is case data in 1990 and the right column in 2017.
Figure 4. Contribution of major depressive disorder and dysthymia to absolute
depression incident cases, both sexes, globally and by region, in 1990 and 2017.
Figure 5. The EAPC of depression ASR from 1990 to 2017, both sexes, by region,
and by types.

16
17
Figure 1. The global disease burden of depression for both sexes in 195 countries and territories.
(A) The ASR of depression in 2017; (B) The relative change in incident cases of depression
between 1990 and 2017; (C) The EAPC of depression ASR from 1990 to 2017. ASR,
age-standardized rate; EAPC, estimated annual percentage change.

Figure 2. The depression cases caused by different types, by SDI regions, from 1990 to 2017.
SDI, socio-demographic index.

18
Figure 3. The incident cases of depression at a regional level. The left column in each group is
case data in 1990 and the right column in 2017.

Figure 4. The EAPC of depression ASR from 1990 to 2017, both sexes, by region, and by types.

19
Figure 5. Contribution of major depressive disorder and dysthymia to absolute depression
incident cases, both sexes, globally and by region, in 1990 and 2017.

20
Conflict of Interest: The author reports no conflicts of interest in this work.