Prevalence and psychosocial correlates of depressive symptom risk among secondary school students in Saudi Arabia: a mixed-methods study.

OBJECTIVES: Adolescent depression is a major public health concern with important psychosocial and educational implications. This study examined the distribution of a depressive-symptom-risk/general-distress composite and its psychosocial correlates among secondary school students in Bisha Province, Saudi Arabia, and explored teachers' perspectives on how depressive symptoms or distress affect students in school settings. METHODS: A school-based cross-sectional mixed-methods study was conducted during the 2024-2025 academic year. Quantitative data were analyzed from 425 secondary school students using a self-administered questionnaire containing a 17-item depressive-symptom-risk composite and psychosocial stressor items. Composite items were coded from 0 to 7 (theoretical total range 0-119; observed range 0-84). For descriptive purposes, four sample-specific, non-diagnostic score bands were used (0-24, 25-38, 39-67, and ≥68), and the primary logistic-regression outcome was dichotomized as 0-24 vs. ≥25. Analyses included chi-square tests, Spearman correlation, Kruskal-Wallis tests, and multivariable logistic regression, with p-values corrected for multiple comparisons using the Benjamini-Hochberg procedure. Qualitative data were obtained through semi-structured interviews with 42 teachers and analyzed thematically. Ethical approval was obtained from the University of Bisha Institutional Review Board. RESULTS: Overall, 47.1% of students had an elevated composite score (≥25). In the 425-student analytical sample, family conflict (aOR = 5.47) and emotional or physical violence (aOR = 3.40) remained significantly associated with elevated scores after correction for multiple comparisons; bullying showed a positive uncorrected association (aOR = 1.68) that did not survive correction. Health-related conditions, smoking, and family history of mental illness were also associated with higher score bands in bivariate analyses. Gender-stratified analyses showed that, after correction, family conflict remained significant among male students, while family conflict and emotional/physical violence remained significant among female students; associations for bullying among males and sexual harassment among females were positive but did not survive correction and should be interpreted as suggestive. Composite scores were not significantly associated with academic performance (CGPA). Teachers reported emotional withdrawal, behavioral changes, reduced classroom engagement, and limited training in identifying and supporting affected students. CONCLUSIONS: Elevated depressive-symptom-risk composite scores were common among secondary school students and were strongly associated with modifiable psychosocial stressors, particularly family conflict and exposure to violence. Because the instrument and its score bands are not diagnostic thresholds, the findings should be interpreted as relative psychosocial/depressive-symptom risk rather than prevalence of clinical depressive disorder. Given the cross-sectional design, these associations are correlational rather than causal. Findings highlight the need for validated school-based mental health screening, teacher training, and family-centered interventions.