Defense mechanisms and quality of life of medical students according to graduation phase.

OBJECTIVES
To compare health-related quality of life (QoL) of medical students in initial and final phases of the program, and to evaluate the association between ego defense mechanisms and specific health-related QoL domains within each group.


METHODS
This was an observational, cross-sectional study. Quality of life was assessed according to the World Health Organization Quality of Life instrument - Abbreviated Version (WHOQOL-Bref); anxiety and depression symptoms were evaluated using the Hospital Anxiety and Depression Scale (HADS); defense mechanisms were assessed using the Defense Style Questionnaire (DSQ-40).


RESULTS
A total of 139 medical students were evaluated. Students in the initial semesters of the program (1st and 3rd) presented more depressive symptoms and worse quality of life in the psychological domain of WHOQOL-Bref when compared to those in the final semesters (8th and 12th). In a later analysis, conducted to identify the variables associated with the psychological domain of the WHOQOL-Bref for each group, both depressive symptoms and defense mechanisms were independently associated with the outcome for medical students in the beginning and in the end of the graduation program.


CONCLUSIONS
Students in the initial phases of medical school may need more specific attention from educational managers. Understanding the role of ego defense mechanisms in the quality of life of medical students may help identify effective psychopedagogical interventions for this population. In addition, the results reinforce the impact of depressive symptoms on quality of life, an association already well evidenced in the literature.


Introduction
Anxiety symptoms, depression and suicidal ideation are not uncommon in medical students and resident physicians. A systematic review on the prevalence of depressive symptoms and suicidal ideation in medical students observed that the prevalence of depressive symptoms in this population was higher than that reported for the general population. 4 Medical school is described as a stressor that can negatively affect the academic performance, health, and psychological well-being of these students. 5 The highly competitive selection before even entering the medical school and later the competitive university environment, not to mention the intense hours and the conviviality with people in situation of illness, can all influence the QoL of the students and medical professionals. In addition to the evaluation of QoL in the different phases of the medical training program, in order to identify phases of greater vulnerability, it is indispensable to study which variables would be associated with the students' QoLthis could help identify interventions that could have an impact on their future professional performance. 6 Most Brazilian medical students are in their adolescence, a period of learning and social development, when they are susceptible to peer influence and the sense of self is in development. 7 The cognitive development of adolescents includes the development of more advanced reasoning skills, the ability to think abstractly and the capacity of more accurately perceiving their own feelings and how others perceive them. 8 Psychosocial and emotional development is characterized by increased autonomy, the establishment of identity and better selfregulation of emotions. 8 In addition, as they mature, stronger regulatory control is achieved, allowing delay in gratification and improved long-term planning. 7 The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines a defense mechanism as "mechanisms that mediate the individual's reaction to emotional conflicts and external stressors. Some defense mechanisms are almost invariably maladaptive.
Others may be maladaptive or adaptive, depending on their severity, inflexibility and the context in which they occur." 9 This is a concept derived from psychoanalysis and represents unconscious resources used by the ego to reduce the conflict between the id and the superego. 10 In a prospective study, George Vaillant accompanied 30 physically healthy men selected from a sample of 268 male university students with the goal of ranking ego defense mechanisms. From this study, which made it possible to map the defense styles of the participants, Vaillant classified the defenses as "immature," "neurotic," and "mature." For the author, the ego's primitive mechanisms evolve into more mature mechanisms. In addition, individuals with mature defenses would exhibit optimal adaptation to life, while those with immature defenses, only a regular adaptation. 11 In the research literature, we observed that only a small number of studies evaluated the association between defense mechanisms and QoL, and few have adjusted the findings for psychiatric symptoms -a relevant confounder in QoL research. In a crosssectional study, Vojvodić et al. found that military personnel that use mature defense mechanisms have a better perception of QoL. 12 Talepasand &   Mahfar evaluated the relationship between defense   mechanisms and QoL among women with breast cancer in a correlational study. The authors found and inverse association between displacement and regression defense mechanisms and physical, cognitive and role aspects of QoL. 13 Only one study has investigated this association in medical students. 14 Thus, the objectives of this study were to compare the medical students' QoL in different phases of the medical program, and to identify the sociodemographic, clinical and defense mechanisms associated with QoL in a Brazilian sample of medical students. Considering that the impact of the imminent beginning of professional life and the greater responsibility with patients grows in importance towards the end of the program, our hypothesis was that students attending the final semesters would present worse QoL when compared to students in the initial semesters.

Study design
This was a cross-sectional, observational study.

Participants
The medical program at Universidade Federal de Santa Catarina (UFSC) is structured in 12 semesters, with activities being held in the community since the early semesters. The two first semesters are dedicated to basic theorical disciplines; from the 3rd semester onwards, focus is on the study of health conditions. The 8th semester is the last one predominantly theorical before the internship (9th to 12th semester). The use of active learning methodologies, in which students are more involved in the teaching process, despite being increasingly stimulated in the pedagogical process, is not mandatory.
Our sample comprised students attending the 1st, This instrument has been validated for application in the Brazilian population. 15 The WHOQOL-Bref is one of the most widely used research tools for assessing QoL in mental health. It accesses the individuals' perception within their cultural context and value systems, taking into account their goals and concerns.

Hospital Anxiety and Depression Scale (HADS)
The HADS scale was developed to assess anxiety and depression symptoms in patients hospitalized for non-psychiatric illnesses and it was subsequently validated for outpatients and non-diagnosed patients.
HADS is a self-administered scale that can also be applied by an interviewer and is valid for measuring Simple linear regression analysis was used to evaluate which variables were associated with QoL domain scores for each group separately. Associations whose p-value resulted < 0.20 were included in a multiple linear regression model. After these last analyses, p-values < 0.05 were considered significant.

Ethical aspects
The research project was approved by the research ethics committee of UFSC. All participants signed an informed consent form prior to data collection.

Results
Among the 196 students enrolled in the 1st, 3rd, 8th Students attending the 1st and 3rd semesters were grouped and referred to as "initial phases," whereas students attending the 8th and 12th semesters were grouped and referred to as "final phases." The comparison between these two groups showed that students in the initial phases presented significantly more depressive symptoms -median of 5 points on HADS-D (interquartile range [IQR] = 3-7) -when compared to students in the final phases -median HADS-D score of 3 (IQR = 2-6) (p = 0.01). In relation to defense mechanisms, students in the initial phases also had significantly higher neurotic (p = 0.004) and immature (p = 0.006) scores; in the assessment of QoL, students in the initial phases presented worse QoL in the psychological domain (p = 0.008) (   The standardized residuals from both multiple linear regression analyses followed a normal distribution, according to the Kolmogorov-Smirnov normality test (p = 0.98 and p = 0.85 for the 1st/3rd and the 8th/12th semester regression models, respectively).

Discussion
In this study, medical students in the initial phases   i.e., better psychological QoL was associated with higher scores on the mature factor. 23 Thus, it is possible that the defenses predominantly required at the beginning, at the end of graduation and in the medical practice are distinct, transitioning between the immature factor at the beginning of graduation, through the neurotic factor at the end of graduation, and finally the mature factor when the profession is at more advanced stage of consolidation, which could be a consequence of both age and professional experience.
We observed that the students in the initial phases of health of newcomers to medical school. 24 However, contrary to our results, Alves et al. 25 and Chazan et al. 26 found a greater impairment of the psychological QoL in medical students in the final phases of the program.
In order to evaluate the relationship between curricular structure and well-being in medical students in the period of preclinical activity (1st and 2nd year), Reed et al. measured the structure of the curriculum through the hours dedicated to didactic experiments, clinics and exams. The results showed that students whose curricular structure presented a greater percentage of hours with clinical activities reported less wear and stress and a lower tendency to drop out of the program. 27 In other words, the absence of contact with medical practice in the early phases of graduation may also be a factor that contributes to increased stress and, consequently, a worsening in psychological QoL.
This study has several limitations that should be addressed. First, the 12th semester is probably an atypical period of medical school, since several -if not all -medical students are also preparing themselves for the medical residency exam, which could increase their stress. In addition, the 8th semester may be more similar in scope to the first half of medical school than the second one. In this sense, perhaps a comparison between the first four semesters vs. the four last ones could be more appropriate for the aims stated in this study. Second, clinical information about alcohol use lacks validity, as we have not used a validated tool for this evaluation. Third, it is not possible to discard a type II error, as we have not calculated the minimum sample size necessary for finding a specific effect size established a priori.

Conclusions
Different defense mechanisms seem to be related to psychological QoL at different moments of the medical graduation program, which may reflect not only the age and experience acquired during training, but also aspects related to the transition phase (high school to college) and curricular structure (greater volume of theoretical than practical activities). Thus, this study draws attention to an aspect often neglected in studies related to QoL, namely, the potential role of defense mechanisms for the planning of psychopedagogical strategies. In addition, the results reinforce the impact of depressive symptoms on QoL, an association already well evidenced in the literature.