Home Archive Vol.37, No.1, 2011 Original papers Contributions to the Study of Depressive Phenomenon in Medical Students

Contributions to the Study of Depressive Phenomenon in Medical Students

A.A. Cupşa(1), T. Udriştoiu(1), Liliana Marinescu(2), I. Andronic(1), Florina Nechita(1)

(1) Department of Psychiatry, University of Medicine and Pharmacy in Craiova; (2) Universitary Hospital „V. Babeş” in Craiova 

Abstract: Although the educational environment is unanimous recognized worldwide as having a high vulnerability to mental disorders, there is a lack of studies on a large scale concerning this matter in our professional literature. The investigation intended to prove the existence and epidemiological-clinical characterization of the depressive phenomenon in a local medicine faculty, with reference to a group of young people of similar age from non medical branches. The prospective study, compared and randomized, initiated in the Faculty of Medicine in Craiova (target group, 655 subjects), in 2008, had as control group young people of similar age belonging to the local academic and non-academic environment (310 subjects). The Zung Depression Scale (SDZ) has been used both anonymous and voluntary. At the Faculty of Medicine, the prevalence of students with scores higher than SDZ scale cutoff (i.e. 50) was 28,2 ± 5,5%, and the level of the control group was 18,2 ± 2,8% (chi2= 8,88, p=0,002). Female medicine students were more significantly affected than the control group (153/512 vs. 52/231 - chi2 4.33 p = 0,037). The prevalence of responders with scores SDZ ≥ 50 for the Medicine group showed in both genres maximum values at the extremes of educational cycle (30,7% in the 1st and 2nd years, and 31,4% in the finishing years) and a minimum in the transition period (22,2%).For the Faculty of Medicine, compared with control groups, there has been a prevalence of the scores compatible with the mild forms of depression. There have been highlighted both individual and socio professional group particularities in circulating and aggregating the depressive symptoms in variable size clusters, from those with non clinical significance to those compatible with clinical and sub-clinical depression.

Keywords: depression, medicine students, Zung depression scale, epidemiology


Background

Depression and anxiety are common presences in the academic community, as shown in numerous studies and reports from various countries, all over the world. [1, 5, 24, 21, 30, 35, 41]. Medical educational environment includes a particular population segment in terms of both professional characteristics and the mental health.  Several studies underline that a medical student has an increased vulnerability to mental disorders associated with stress factors acting, often combined, in very different ways in a demanding environment, competitive and appreciative, but also authoritarian, traditionalist, restrictive and with limited flexibility.  [3, 6, 7, 8, 12, 13, 17, 28, 44].

Persistent exposure of the medical students at a high risk of stress [3, 6, 8, 9, 16, 19, 20, 34, 36, 43, 44] is a constant threat not only for their health but also for the performance, skills and attitudes that people expect from the new generation of medical doctors. [11, 15, 22, 23, 29, 32]

Objectives

The study originated in the lack of studies on depression among Romanian medical students, our approach aimed to identify the existence of the phenomenon in a local medical school, the prevalence and distribution of subjects consistent with clinical depression, and weight and structural categories of the attributes of depression in the young people.

The results could support the initiation of directions and priorities for further research, the policy and institutional strategies to monitor and control the phenomenon of depression in the medical academic community. The study being ongoing, the data presented are the primary results of a large survey of the phenomenon of depression in medical students and non-medical academic peers and non-academic local young people.

Materials and methods

Prospective study, randomized, control group study, initiated in the academic year 2008/2009 in the University of Medicine and Pharmacy in Craiova (U.M.F), including students from the Faculty of Medicine (target group) and a control group consisting in young volunteer responders of similar age, randomized selected from the local non-medical academic and non-academic peers.

Among the MCQs  distributed to the potential responders , outside exam periods, was also included Zung Depression Scale (ZDS), which includes 20 items aimed at the symptoms (attributes) of depression, organized in four structural categories: pervasive affective disturbance (depressed affect, crying spells), physiologic disturbances (diurnal variation, sleep disturbances, decreased appetite, weight loss, constipation, tachycardia, fatigue, decreased libido), psychomotor disturbances (psychomotor agitation, psychomotor retardation), psychological disturbances (irritability, indecisiveness, confusion, dissatisfaction, hopelessness, emptiness, personal devaluation, suicidal rumination).

Designed in Lieckert system, the scale demands  from the subjects answers quantifiable in  four levels of weight, according to the presence of the depressive symptoms  during the past two weeks (1 = None/a Little of the Time, 2 = Some of the Time, 3 = Good Part of the Time  4 = Most /All of the time). As a safeguard and to avoid the bias, half of the statements are equally worded symptomatically positive and negative.

The questionnaire is self-rated and requires less time to complete (5-30 minutes), is easily manipulated and quantified, suitable for statistical processing. The final aggregate score is indexed indicates the presence of symptoms that may be of clinical significance (if they are above the 50 points, the cutoff  for corresponding clinical depression [46] At the same time, the scores  provide information about intensity of the depressive disorder (50-59 – minimal to mild, 60-69- moderate to marked,≥ 70-severe to extreme depression). Zung Scale has a sensitivity of 97% and a specificity of about 67% [16] and a split-half reliability between 0.81-0.94 [7]

The questionnaires were centralized in a database, along with others converged data, and then subjected to statistical processing (Excel, MedCalc): descriptive analysis of target location (mean, median), dispersion (standard error, standard deviation), shape (variance, kurtosis, skewness), intervals of confidence, analysis of the relationship between variables (dependence) - matrix correlation and index of correlation Pearson, analysis for statistical significance - the t test for comparing averages of two groups chi2 and p-value of significance (Fisher's exact test for small groups), one-way ANOVA test for comparing multiple media groups.

Because the self-rating scale was completed anonymously, for ethical and professional reasons, it was offered to the responders the possibility, by using a pseudonym, to request to a special email address the out coming of the evaluation together with the appropriate recommendation (e.g. opportunity to visit a specialist)

Results

From general data about the monitored groups (Table no. I), one observes a similar percentage of responders and comparable gender distribution (chi2 = 0.81, p = 0.36 respectively chi2 1.58 p = 0.208); for age, although average values are close, the difference is significantly higher in medicine, where were included individuals from all the years of study (ANOVA one-way, df = 1, F = 8.29, p = 0.004).

Table no. I. Responders main features

Target

groups

Questionnaires distributed

Responders

No.

%

Age (media, SD, y)

Females

Males

No

%

No

%

Medicine

725

655

90,3

21,7±0,8

512

78,2

143

21,8

Preclinical years.

(I +II)

225

202

89,7

19,6±0,9

163

80,7

39

19,3

Transition years.  (III+IV)

250

230

92,5

21,7±0,9

179

77,8

51

22,2

Clinical years. (V+VI)

250

223

89,2

23,7±0,8

169

75,8

54

24,2

Control

350

310

88,6

21,4±2,4

231

74,5

79

25,5

Grand total/media

1075

965

89,7

22,5±1,6

743

77

212

23

Main demographic data for the study and control groups, and medical responders grouped by level of training (preclinical, transition, clinical) are summarized in the table no. II. Comparative analysis of the data of the medical students with those of the witness shows  statistically non-significant percentage differences regarding the gender distribution (OR 0.824, CI 95% 0.60 - 1.12, chi2 1.14, p = 0.22), child's rank (OR 1.16, 95% CI 0.70 - 1.93, chi2 0.36, p = 0.54), the „unmarried/bachelor” condition (OR 0.81 Ci 95% 0.57 - 1.13, chi2 1.46, p = 0.22) and significant in terms of membership in families with fewer children (OR 0.40 Ci 95% 0.30- 0.53, chi2 40.4, p <0.0001 ) belonging to urban area (OR 0.58 CI 95% 0.41- 0.82, chi2 9.47, p = 0.002) and the divorcee condition  (Fisher-t p = 0.032).

Characteristics of the groups pursued are comparable, as shown in the data box. I

General and on gender prevalence of the responders with scores above the cutoff of ZDS, (e.g. consistent with clinical depression) are shown in the table III

Among  medical students, the percentage of those with scores ≥ 50 in the overall group was 28.2 ± 5.5%, while in the control group it was 18.2 ± 2 8% (within that, only students at the University have been 16.7 ± 1.34%). The difference in prevalence between groups is dominated by medicine (chi2 = 8.88, p = 0.002). The medical female students’ involvement was significantly higher than the control group (girls: 153/512 vs. 52/231 chi2 - 4.33 p = 0.037) but for the males, the percentage difference is non-significant statistically (30/143 vs 7/49 chi2 1.05 p = 0.305).

Table no. II. Main demographic data

Variables

Response type

I-II years

 III-IV years

V-VI years

Medicine Group

Control Group

No

%

No

%

No

%

No

%

No

%

Gender

Male

39

19.3

51

22.2

54

24.2

144

22.0

79

25.5

Female

163

80.7

179

77.8

169

75.8

511

78.0

231

74.5

Child rank

Rank I

123

60.9

124

53.9

137

61.4

384

58.6

187

60.3

Rank II

61

30.2

83

36.1

71

31.8

215

32.8

100

32.3

> Rank II

18

8.9

23

10.0

15

6.7

56

8.5

23

7.4

No. of siblings

Single

46

22.8

23

10.0

44

19.7

113

17.3

48

15.5

2 children

113

55.9

140

60.9

112

50.2

365

55.7

114

36.8

>2 children

43

21.3

67

29.1

67

30.0

177

27.0

148

47.7

Origin

Urban

170

84.2

198

86.1

195

87.4

563

86.0

242

78.1

Rural

32

15.8

32

13.9

28

12.6

92

14.0

68

21.9

Marital status

Single

184

91.1

192

83.5

161

72.2

537

82.0

244

78.7

Married/ concubine

14

6.9

38

16.5

53

23.8

105

16.0

65

21.0

Divorced

4

2.0

0

0.0

9

4.0

13

2.0

1

0.3

Box no. I Responders’ main common features

Faculty of Medicine (about 22.5% of the students):

  • Women: men ratio - 4:1
  • Predominance of single or low rank children in the family (91.5%)
  • Origin of the majority in families with 2 children (55.7%)
  • The absolute majority of urban origin (86%)
  • Absolute predominance of the unmarried people (82%)

Witness Subjects (about 35 % of the non-medical socio-professional group)

  • Women: men ratio - 1:3
  • Predominance of single or low rank children in the family (92.6%)
  • Origin of the majority in families with 2 children (47.7%)
  • The absolute majority of urban origin (78.1%)
  • Absolute predominance of the unmarried people (78.7%)

 

Table no. III. Prevalence and gender distribution of subjects with ZDS scores above the depressive cut off

Group

ZDS score

No of subjects with ZDS score ≥50

%

Females

Males

No.

%

No.

%

Faculty of Medicine

43,4±10,1

183

28.2

153

83.6

30

16.4

Control

43,7±10,2

59

19

52

88,1

7

11,9

Concerning the prevalence of the responders with ZDS scores ≥ 50 at the Faculty of Medicine group, for both females and males, however, different values were recorded​​depending on years of study, with the maximum at the extremes of the educational cycle (30.7% during the preclinical, and 31.4%, respectively, in the final years) and a minimum for the transition period (22.2%). Thus, chart appearance was a "V" shaped curve (Fig. 1)

Fig. no. 1 Prevalence of the medical students with ≥ 50 ZDS scores according to years and cycles of study

If the average ZDS indexed score / subject (table III) in medical students and witnesses groups is very similar (Fisher-t = 0.627, p = 0.534), the responders’ distribution on decimal ZDS score tier analysis showed particular aspects (table. IV).

Table no. IV. The responders’ distribution by tiered decimals ZDS scores

Groups

Responders

Tiered decimals ZDS scores

Grand total

≤ 29

30-39

40-49

50-59

60-70

≥70

I+II years

Nr

14

84

43

44

8

9

202

%

6.9

41.6

21.3

21.8

4.0

4.5

100.0

III-IV years

Nr

5

90

83

32

16

4

230

%

2.2

39.1

36.1

13.9

7.0

1.7

100.0

V-VI years

Nr

14

67

72

54

14

2

223

%

6.3

30.0

32.3

24.2

6.3

0.9

100.0

Faculty of Medicine group

Nr

33

241

198

130

38

15

655

%

5

36.8

30.2

19.9

5.8

2.3

100.0

Control

group

Nr

21

82

148

25

32

2

310

%

6.8

26.5

47.7

8.1

10.3

0.6

100.0

One notes that 274 (41.8%) of medical responders lie between 0-39 points and they are basically those to whom most ZDS depressive symptoms are reported predominantly as " none/a little of the time”, and/or “some of the time” in the period immediately preceding the test administration. In the control group, 103 responders (32.9%) meet this condition, but the superiority of the medical weight is significant (chi2 = 6.55 p = 0.01).

In the interim zone  (i.e. around the 50 points depressive cut-off),   were located 328 medical students (50.1%), and among them 130 students (19.8%) have had values between 50 and 60 points (corresponding to clinic mild depression).- In the control group, 173 responders (55.8%) were located close to the depression threshold of the scale, but without significance compared with medical students’ situation (chi2 = 2.77 p = 0.096); of these, only 25 subjects (8.1%)  were clinically compatible with mild depression symptoms. This prevalence was significantly lower than that of the medicine group. (chi2 = 33.62, p <0.001).

In the zone with ZDS scores o≥ 60 points (values compatible with moderate / severe clinical depression) have been  identified 53 medical students (8.1%) and 34 subjects in the control group (11.6%), but the percentage difference is not significant ( chi2 = 2.12 p = 0.14).

Mean scores of the ZDS structural sub-categories of depressive symptoms, presented in table V according to the position of the subjects to the threshold of depression, are higher in most cases of the control group compared to those of medicine. (p<0.05). An exception is in the subcategory of psychological distress, with a higher average to medical students, but without significance in comparison with the controls (Fisher p = 0.055 t 3.71)

Table no. V. Average scores of the structural subcategories of depressive symptoms in relationship with the ZDS cut-off

ZDS scores

Study groups

Pervasive affective disturbances

Physiologic disturbances

Psychomotor disturbances

Psychological disturbances

Average Zung scores

Media

DS

Media

DS

Media

DS

Media

DS

Media

DS

 ≥50

Faculty of Medicine

5.24

1.68

22.14

3.45

5.22

1.55

23.87

4.82

56.47

6.64

Control group

5.75

2.01

24.80

3.61

6.59

1.51

24.60

3.16

61.71

4.96

 <50

Faculty of Medicine

3.45

1.14

15.95

3.08

3.56

1.36

15.32

3.42

38.27

5.64

Control group

3.64

1.23

16.60

3.23

4.75

1.87

14.88

3.09

39.85

5.77

The analysis of the depressives symptoms in relation with the overall score achieved by each of the 20 included in the ZDS has allowed a classification according to the individual amount. In Table no. VI are presented in decreasing order of  total value the medical responders’ depressive attributes who have exceeded 10% of the general Zung score of the group and the corresponding pairs of the control group. In medical students the top is dominated by psychological disturbances and outlines a core depressive anxiety. The control group was dominated by psychological and somatic symptoms, the latter forming a somatic depressive core well-defined


Table no. VI. The main depressive symptoms in relationship with the ZDF cutoff value

No

ZDS score ≥50

ZDS score < 50

Medical students

Controls

Medical students

Controls

Symptoms

Score log10

Symptoms

Score log10

Symptoms

Score log10

Symptoms

Score log10

1

Indecisiveness

2.84

Sleep disturbances

2.82

Diurnal variation

3.16

Sleep disturbances

2.89

2

Irritability

2.83

Libido

2.77

Decreased appetite

3.09

Decreased libido

2.81

3

Devaluation

2.78

Psychomotor agitation

2.76

Indecisiveness

3.06

Psychomotor agitation

2.8

4

Hopelessness

2.77

Tachycardia

2.73

Devaluation

2.98

Tachycardia

2.75

5

Diurnal variation

2.76

Dissatisfaction

2.69

Hopelessness

2.96

Dissatisfaction

2.73

6

Decreased appetite

2.76

Indecisiveness

2.67

Psychomotor agitation

2.96

Psychomotor retardation

2.73

7

Confusion

2.75

Emptiness

2.67

Confusion

2.95

Indecisiveness

2.72

8

Fatigue

2.75

Confusion

2.67

Constipation

2.95

Emptiness

2.7

9

Dissatisfaction

2.73

Psychomotor retardation

2.66

Dissatisfaction

2.95

Constipation

2.68

10

Psychomotor agitation

2.72

Fatigue

2.65

Irritability

2.94

Confusion

2.68


Discussions

The study aimed to identify and describe the main epidemiological features of the depression phenomenon in the medical students’ community with reference to a local group of young people of similar age from non-medical social-professional fields. Because we did not find reliable information regarding the prevalence of depressive distress in medical students in Romania, we have referred to international data. In our study, the average prevalence of medical students identified with ≥ 50 ZDS indexed scores was significantly higher than the control group.

In the world, college students reported higher levels of prevalence of depressive disorders than the general population mean [5, 17, 21, 30, 31, 34, 41], especially in medical faculties. [12,13,14]

In the last quarter century, in medical students were reported varied prevalence of depression, with or without anxiety. For example, in U.S we found values between 12% and 25% [9, 19, 37], in Brazil - 32% [6], in Dubai - 28.6% [2], in Beijing and Hong Kong - 33.7% and respectively  61.5% [38], Pakistan - 42.9% [25], and Nigeria -23.3% [4]. Our data were included in these limits and are over the prevalence of depression in European general population (13%) [42].

To Spiesel’s observation [39], that whole process of medical education is a major stressor, one can add that the entire medical career is putting a heavy strain on the health (physical, mental, spiritual) of those who practice. Among the identified stressors over time, Goebert. D et al. qualify as frequent: busy work, sleep deprivation, difficult patients, inadequate learning environment, financial problems, pressure of the information, career planning [18]. By stressing a pressure on many of the actors in the medical field, people with various skills of resilience, result increased vulnerability to depression and anxiety. [26, 27, 33, 45].

In our study, we identified differences in prevalence of depression scores in the various stages of academic education: higher in both preclinical (I-II) and terminal (V-VI) years of study along with minimum values during transition (III-IV) , with a graphical representation of the prevalence in a "V"  shaped curve. Other authors have also found such differences in the prevalence of anxiety and depression correlated with academic educational attainment. [9, 33, 37, 18].

At the beginning of the college,  medical students have a mental health similar with other young people of the same age but, unfortunately, over the years of studies, it often gets worse in some of them [3, 6, 8, 9, 18, 20, 32, 36] The sources of psychological stress for medical students obviously vary depending on years of study. In the first year of training, in the emancipated identity building period, many students are suddenly faced with leaving home and traded separation from the natural parents, separation from friends, but also with problems of integration into a new system of education. Just admitted - often through a rigorous selection system - young people must cope quickly with complex academic environment and, at the same time, to integrate into a group of peers, similar in motivation and intelligence. Dissection of human bodies is a known stressor [20] but also other stress factors such as the increasing workload and learning, concern for performance, in an extremely proud and competitive educational environment, are characteristic for this transition period [40]

With the entry into clinical years, students will break the initial groups, and begin the rotations from a specialty to another, constantly changing environment, surroundings, conditions and/or requirements. Each training request a specific set of knowledge and skills, which emphasize training deficits rather than positive accumulating. The learning, program unstructured routinely, exposure to human suffering in hospitals, lack of leisure time, concerns about the financial situation, are all additional sources of psychological stress characteristic of this period [10] In the final years one add the future job worries, imposture syndrome, thoughts on starting a family or paying bank debts for the studies a.s.o.

Symptoms of depression are common to all young people, but one describes quantitative and qualitative differences between the sexes, years of study, specialization, curriculum, working milieus etc. Many students have subclinical forms of depression, according to Survive the American College Health Association, 45% of the females and 36% of the males would present in 2006 such disorders [1] From our data results that during 2008/2009, in the off exam sessions time, medical students with ZDS scores of depression had as dominant attributes: indecisiveness, irritability, personal devaluation, diurnal variation and change in appetite. The control group was dominated by: sleep disturbance, change in libido, psychomotor agitation, tachycardia and dissatisfaction.

The group of medical students with Zung scores ≥ 50 points have a core of depression with anxiety as a consequence of multiples stressors acting in the community convergent with their own vulnerabilities. . In the control groups with similar scores, the depression somatic attributes are dominant and may be the result of economic-social pressures with physiological changes, which may often be accompanied by psychological disturbances

If differences in depressive profile of communities is a recognized phenomenon in literature, when one talk about individuals depression each subject express his/her depression in a personal equivalent. Using an  self-assessment, it seems natural that medical students are prone to give different meanings or nuances, and they seemed to perceive or to be concerned with rather more abstract and subtle attributes of the psychological sphere, while their non-medical peers feel as a priority and report the somatic components of depression. These differences in presentation, reflected in the  ZDS scores for structural categories, are represented by the different quality of depressive symptoms, such as intensity / persistence;  a ranking of the first 10 symptoms according individual total ZDS scores per attribute confirm the importance of the type of each symptom. But quantitative aspects are also involved , the depressive attributes aggregate variable in clusters with different weight in the general depression score.

Higher values recorded in the control group are correlated with an increased intensity of the depression. In medical students - albeit with a higher prevalence – on dominates the mild forms of depression. The aspect is actually reported in the literature [24]

Final observations and conclusions

Based on the results of the screening tests on representative groups for indigenous medical students communities, , the study confirms the existence on a large scale of the complex depressive phenomenon ,  affecting about one third of the students, beyond the level identified in  other non-medical young people. Considering the sensitivity and specificity of ZDS, the dimensions of the phenomenon could be even larger.

Even if the administration of a self-rating test of depression does not allow a clinical diagnosis of certainty, in one's practice specialist interview is mandatory, the previous conclusion concerning the locally depressing phenomenon remains valid, and confirms for Romania that medical academic environment is one particular depressive and an anxiety generator

In the community of medical students, compared with control groups, dominated ZDS scores compatible with mild / moderate depression.

There are individual features but also socio-professional group related in the movement and aggregation of the depression symptoms in complex of attributes of varying sizes, ranging from those without clinical significance to those compatible with the subclinical and clinical depression.

Considering this data, it is extremely important that the managers of medical faculties and all the faculties should become aware of the importance of the phenomenon of depression and negative consequences on the personal and professional students and young doctors evolution and participate actively in preventing and maintaining it under control.

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Correspondence Adress: A.A. Cupşa, MD, PhD student, Department of Psychiatry, University of Medicine and Pharmacy in Craiova, Str Petru Rares nr. 4, 200456, Craiova, Dolj, România; e-mail: cupsa2000@yahoo.com

 


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