Prevalence of depressive and anxiety symptoms in medical students in the city of Santos

Objective Ascertain the prevalence of depressive and anxiety symptoms in medical students, considering data in the literature that indicate higher vulnerability to emotional disorders in this population. Methods A descriptive cross-sectional study with a sample of 657 (98%) students. The instruments used were: questionnaire of socioeconomic-demographic characteristics, Beck Depression Inventory and Beck Anxiety Inventory. Results Predominance of the female gender (61%), aged between 17 and 30 years (98%), Catholic religion (64.2%) from the city of Sao Paulo (40.7%) and other cities in the state (35.7%); 30% presented depressive symptoms and 21% anxiety symptoms. Female students had higher scores both for depression (34.8%) and for anxiety (26.8%). As regards the course year, the highest rates were found in the 5th year (40.7%) for depression and in the 2nd year for anxiety (28.8%). Conclusion The data obtained in this study (30%) agreed with the literature regarding the prevalence of depressive symptoms in medical students, but this index was higher compared to the population in general (15.1% to 16.8%), and related to people in Sao Paulo city (18.5%). Concerning anxiety the rates found were slightly lower than those in specific literature but higher than those in literature for the population in general (8% to 18%) and in city Sao Paulo (16.8%). These indices indicate that the school of medicine may play a role as a predisposing and/or triggering factor in some students. The results suggest that more attention should be directed to 5th year students, who are beginning the internship period.


INTRODuCTION
Studies indicate that the course of Medicine is a period of significant anguish for students of this field and that the prevalence of depressive and anxiety symptoms is higher among them than in the general population [1][2][3] .
In several parts of the world, such as the Middle East, Europe, USA and South America research is carried out on this topic 2,4 . In Brazil, reports on mental health of these students are present in schools of medicine in almost every state in the country 3,[5][6][7][8][9][10][11] . Such studies reflect concern about the physical and psychological well-being of students enrolled in the course of Medicine 1,3,5-11 . It should be asked what happens with this population, which is so intellectually capable as to achieve success in very competitive entrance exams to schools of Medicine, but somehow are more vulnerable to stress and, consequently, to the onset of psychological disorders 10,11 .
Stressful factors inherent to the academic process are pointed out as possible causes of the origin of emotional problems 1,3,5,7,9,10 . Emotional intelligence, i.e., "the ability to identify our feelings and the others; to be motivated and to manage well our emotions inside ourselves and our relationships" 12 , linked to personality traits which will play an important role in facing these situations in the under graduate period. Investigation of this subject was intensified when it was found that some students became vulnerable to the onset of affective disorders during their college years, the most frequent alterations being of a depressive and anxious nature 1,6,10 .
Depression is a disease of different etiologies, characterized by severe clinical manifestations and significant behavior alterations. When it is not adequately diagnosed and treated it results in important distress to the individual, rendering him incapable of work, social and family life 13 . A population study carried out by WHO on the global depression map develop through OMS and covering 18 countries, found that, for most of the cases, the age of symptom onset was between 24 and 25 years and prevalence among women was twice as high as in men 14 . The rates of humor alterations in the general population indicate prevalence between 15.1% and 16.8%, and in São Paulo 18.5% 15 . Projections indicate that in 2020 it will reach 2nd place among the diseases that will most affect developed countries and 1 st place in developing countries 16 .
Anxiety is a feeling of apprehension, disquietude and discomfort when facing expectations of a future threat, accompanied by somatic signs indicative of nervous system alterations 17 . It is considered pathological when very intense or out of proportion to the stimulus, significantly affecting the quality of life of the patient 18 . Anxiety disorders are among the most frequent symptom complexes in psychiatry. The first symptoms are manifested in young people, at the end of adolescence and early adulthood. It is 2 to 3 times more common in female students 17 .
In Brazil, the Psychiatric Morbidity Multicentric Study found index from 8% to 18% of anxiety and phobia 19 . The Catchment Area Study, SP-ECA, the Psychiatry Institute of USP Clinical Hospital, performed with 1,464 people, found the index of 16.8% for anxiety disorders. Except for chemical dependency, women had higher risk prevalence for any non-psychotic mental disorder, and these results are in agreement with the literature 15 .
Research seeking associations between psychiatric disorders (especially depression and anxiety) and use of drugs are frequent. Studies demonstrate significant association between the presence of such disorders and use of psychoactive substances, indicating that these individuals present higher risk for drug abuse 19 . The use of drugs facilitates the onset of depression; on the other hand, previous depression is an important factor for the use of drugs 20 .
Upon entering the school of Medicine, the student begins undergoing changes, both in personal and social life; he faces a new reality and has to respond to this situation, which may be adapted or not. The lack of adaptation creates situations of conflict that may trigger emotional disorders, with prevalence of depression and anxiety 1,7,10,21 .
Some scholars begin the course without the exact notion of what a medical career is and at a time of emotional immaturity. The choice of professional identity is sometimes before their own identity as a person. Self-knowledge is important to enable greater emotional balance in the performance of their activities 21 .
Psychological phases experienced by the student during the formative years stand out 1,21 : Depressive and anxiety symptoms in medical students 1) Phase of Euphoria: a moment of great idealization, full of expectations and intense emotional load. The school of medicine is seen by the student as an idealized continent, where there will be no anguish and insecurity but only achievements 1,21 . 2) Phase of Disillusionment: The student gets in touch with the content of the course, the staggering volume of studies, the difficulties of different subjects, the demands of academic training and its inherent challenges 1,21 . 3) Internship Phase: Medical practice begins. The student will have before him a person with whom a doctor-patient relationship will be established, there will be a change of role and function. The fear of making mistakes may generate feelings of anguish, insecurity and impotence 1,6,9,12 . The internship groups are formed, in which personal characteristics will make a difference and be tested, and the students may be accepted by the group or not 1,21,22 . Emotional intelligence, the ability to face conflicts, will be an important factor in the way that the student will handle his own limits and, and anxieties, and how he will prepare his experiences at that moment 1,21,22 .
The emotional experiences, the way he deals with his own limits and anguish, will determine how he will process the experiences of this period 1,7,22 . Aspects of academic training such as excessive pressure, high level of demand imposed on self and on society, overload of subjects, little time for leisure, competitiveness among colleagues, contact with the patient and with death 5,6,23,24 , an idealized image of the physician and the medical student are identified as factors that are detrimental to physical and mental health 1,3,6,11 . However, personality traits, life experience and psychiatric morbidity in the family are etiologic factors considered more important than occupational factors in the determination of vulnerability to stress 22,25,26 . Factors that are inherent to the teaching process may negatively influence the mental health of some students, which will be reflected in his academic performance and his behavior by means of inadequate postures, affecting the manner he will deal with the profession and establish the doctor-patient relationship 6,10,22,26 .
The objective of the present study was to ascertain the prevalence of depressive and anxiety symptoms in medical students at the Centro Universitário Lusíada (Unilus) during 2012 and evaluate if there is correlation between the onset of symptoms and the year the student is enrolled in.

METHODs
A descriptive cross-sectional study with students enrolled in the course of Medicine at Unilus, from the 1 st to the 6th year, in 2012.
The students were oriented about the objectives of the research, its voluntary character and the confidentiality of information, whose results would be demonstrated globally, without individual identification. Those who agreed to participate signed the Term of Free and Informed Consent (TFIC); after these were handed in, they answered the questionnaires. Their application was done by only one investigator, in the classrooms of the 1 st , 2 nd , 3 rd and 4 th years (campus II) and at the teaching hospital (Hospital Guilherme Álvaro) to students of the 5 th and 6 th years, either before or after academic activities, with the agreement and cooperation of the respective professors. The average time for application of the instruments was 30 minutes for each student.
The measurement instruments used were: 1) Questionnaire of socioeconomic-demographic characteristics with the following information: age, sex, marital status, children, city of origin, type of residence, religion, leisure, use of drugs, psychological or psychiatric treatment, professional choice, family income. 2) Beck Depression Inventory (BDI): self-applicable instrument, used to assess depressive symptoms and attitudes. Composed of 21 items, with increasing degrees of intensity of symptoms and scores from 0 to 3. Validated in Brazil by Gorenstein and Andrade 27 . In this study were used the cut-off scores recommended by the Center for Cognitive Therapy: 0 to 10 (absent or minimal), 10 to 18 (mild), 19 to 29 (moderate) and above 30 (severe). 3) Beck Anxiety Inventory (BAI): self-applicable instrument, that measures the intensity of symptoms and attitudes denoting anxiety. Adapted and validated in the Portuguese version by Cunha 28 . Composed of 21 items, with increasing levels of severity, from 0 to 3 points. The Brazilian criteria defined by Cunha were adopted for classification of symptoms -0 to 10 (absent or minimal), 11 to 19 (mild), 20 to 30 (moderate) and 31 to 63 (severe). After collecting data from previously completed form, used the Excel Microsoft ® program, Version 2010, to place the data and subsequent analysis with Statistical Package statistical package for Social Sciences (SPSS version 18 for Windows).
It was first performed descriptive statistics for all variables of interest in the study. Qualitative variables were presented as absolute and relative values. Quantitative variables were expressed through their central tendency and dispersion. In referring to the statistical analytical quantitative variables were initially tested to determine whether they were normally distributed based on the absolute values of the maximum difference between the observed and the expected cumulative distribution cumulative distribution, assuming the assumption of normality by the tests Kolmogorov-Smirnov (with Lilliefors correction) and Shapiro-Wilk. All samples in this study did not meet the normal criteria and were treated as non-parametric and was used chi-square test for extensive tables and Fisher's exact test when necessary. We considered the significance level of 5%.
Approved by the Research Ethics Committee for Human Beings of Unilus protocol number 135/2012.
Among all of the students, 106 ( ) did not answer. The great majority, 636 (96.8%) informed they were happy with their professional choice. Only 29 (4.4%) students were engaged in some kind of labor activity. As to family income, 376 (57.2%) students were in the range of 20 minimum salaries or more, 167 (25.4%) were in the range between 10 and 20 salaries, 74 (11.3%) between 4 and 10 salaries, 22 (3.3%) between 2 and 4 salaries, 14 (2.1%) up to 2 minimum salaries and 4 (0.6%) did not answer.
In this investigation with the students of the course of Medicine at the Centro Universitário Lusíada, the prevalence of depressive symptoms was 30% (Table 2). Comparing the data obtained in this study with others carried out with the same instrument (BDI), slightly higher scores were observed than those found by Macedo et al.   34 in a study with only 6 th year students = 20% of depressive symptoms, this study 6 th year = 18.8%. In this study the score indexes obtained in the 1 st year, as they were the lowest, became reference parameters for the other years of the course. In the comparison among the years, a statistically significant correlation was found for depressive symptoms among students in the 2 nd , 3 rd , 4 th and 5 th years. There was no significance in the 6th year (Table 3 - Figure 1).
When the scores obtained in the BDI are observed for the different years of the course, there is agreement among the several studies in which the lower scores are found in the 1 st year, indexes easily understood when it is considered that the student is experiencing a moment filled with fulfillment and achievements 1,6,21 .
When scores are stratified by year of the course, a marked increase is seen in the scores from the 1 st (17.2%) to the 2 nd year (35.6%). Such figures agree with studies that point out to increase in scores obtained from the 1 st to the 2 nd or 3 rd year 4,5,23,33 . These results may be explained considering the progression of the own student 5 : after an initial period of euphoria, follows the "phase of disillusionment", when the demands of academic training and the difficulties inherent to it stand out. At this time the student perceives that achieving the so ardently desired place in the course of Medicine has a price and now he will have less availability for family and social activities 1,21 .
Later on there was a slight decline in the depression rate from the 2 nd year (35.6%) to the 3 rd year (32.6%), which remained relatively stable in the 4 th year (34.9%), suggesting a possible adaptation to the teaching method and the course dynamics 1 . From the 4 th (34.9%) to the 5 th year (40.7%) there was a new increase, the scores found in this year being the highest among the other years of the course. These results are probably associated with alterations that take place in this phase, when the medical student, already at the teaching hospital, begins to have closer contact with the patients and there is a transition from the academic to the professional model. It is also in the 5 th year that the internship period begins and with it the difficult task of forming groups, when, more that the academic performance, the personal characteristics will be tested and the students may be accepted by their colleagues or not 1,21 . At this institution, it is a known fact that situations of conflict among the students have occurred, when by their own personality characteristics they found it difficult to establish bonds that would reflect in relationships with colleagues, who were directly or indirectly excluded from the other groups, generating feelings of rejection and abandonment. Another aspect that may be related to the recrudescence of symptoms is the psychological stress presented by some students when they have to deal with the pain and the suffering of another human being 6 . Some of them live this phase intensely and with much distress, with negative effects on their well-being 10,22,34 . In the 6 th year there was decrease in scores of depressive symptoms (18.8%); these results disagreed with the literature, which showed studies pointing to higher rates in the last year of the course 11,23,31 associated with a period with a heavy load of study, duty schedules, high competitiveness with preparation for the residency exam and doubts regarding the specialty, many times hindering the personal and social life of the student 1,10,22,31,34 . In this educational institution   (Unilus), the medical school structure on the 6 th year is similar to the 5 th year; thus, it is believed that the difference found in this study in relation to the literature, it is because the student already faces the difficulties on the 5 th year, and the rates found at this time of course were the highest, which probably justifies lower scores for depressive symptoms in the 6 th year.
On the other hand, through the socioeconomic-demographic questionnaire it was ascertained that the percentage of female students is higher than the percentage of male students at this institution, around 60% and 40%, respectively. Comparing the scores obtained in the BDI between these two groups, it was found that there is predominance of depressive symptoms among women in each year of the course and in the total number of students ( Figure 2). This difference was statistically significant particularly in the 4 th year, indicating that female students are more vulnerable to the onset of depressive symptoms compared to men. These results agree with those found in the literature, both for the general 19 and the specific populations 2,5,8,9,11,31,33-35 . mes higher (27% -only with 6 th year students) 34 24 and Souza (Curitiba/PR, 2010, n = 359) 11 obtained high rates for symptoms anxious. Note that the comparison is questionable due to use of different measurement instruments.
When BAI results were stratified per year of the course, considering the 6 th year as reference (lowest scores: 9.9%), the rates found in the 1 st year (18.4%) were not statistically significant. As was found for depressive symptoms, in the 2 nd year there was also an increase in anxiety scores (28.8%), in agreement with other studies 4,11,36 , followed by a decrease that remained basically the same in the 3 rd (22.2%) and 4 th years (22.9%). A slight elevation was found during the 5 th year (27.9%) (Table 5 - Figure 3). The increase in prevalence rates for anxiety symptoms may be understood considering the same stressful factors experienced by students presenting depressive symptoms.
Studies identify the last year of the course of Medicine as a moment of crisis with a high degree of stress, worsening of the quality of life and, therefore, higher prevalence of symptoms related to psychiatric disorders 7,11,29,36 . The statistical results obtained in this work detected a marked diminution of symptoms in the 6 th year (9.9%) in comparison with the previous years, and consequently did not confirm the data in the literature (Table 5 - Figure 3).

Anxiety
As regards anxiety, a smaller number of articles was found in scientific literature, sometimes carried out with different instruments, which makes it more difficult to compare results. This study found a 21.5% prevalence of anxiety symptoms (     Depressive and anxiety symptoms in medical students As stated above, we believe that once you are on the 6 th year, the student has already gone through the adaptation process on the 5 th year. In this teaching Institution (Unilus), the structure of the course of Medicine in the 6th year is similar to that of the 5 th year, which probably justifies the adaptation of the students in the final phase.
Seeking to better understand these issues, it is our belief that one of the hypotheses is that at this moment the student is overcoming difficulties and managing to adequately deal with his own limits, experiencing specific situations of the end of the course as a development process of emotional maturity and growth 34 . Another hypothesis, of greater concern, is that in face of high rates of depressive and anxiety symptoms, associated with limitations imposed by an intensive load of study and training, the student is developing mechanisms of compensation, dealing with difficulties by means of inadequate strategies, which oftentimes may signify clinical expressions of psychological stress 3,34,37 .
As regards gender, higher symptom scores were found among the female students in every year of the course and in the global result, especially in the 4 th year when a statistically significant difference was detected between men and women, indicating that the female sex presents a considerably higher risk for anxiety in relation to the male (Figure 4). These findings agree with the general 15 and specific literature, in which other studies confirm greater vulnerability of female gender to disorders of this nature 8,11,31,32 . These data are particularly significant when it is considered that, in the last few years, there was an important escalation in the number of women in medical schools, and that in many of them, such as in this institution, where this work was carried out, they constitute the majority of students. In face of several studies, rectifying that there is prevalence of depressive and anxiety symptoms in the female gender, it is questioned which would be the specific characteristics of women that would justify these rates. Seeking to answer these questions, it is concluded that female students present different reactions in stressful situations, are more sensitive and therefore more affected by the feelings of the patients; on the other hand, these characteristics afford to the female gender a greater capacity for empathy 11 .
Another aspect that should be observed is the correlation between psychiatric disorders and the use of drugs. Studies confirm that individuals that present these symptom complexes are at a higher risk for abuse of licit and illicit substances 15 . The use of drugs may trigger depression; in addition, previous depression is an important factor for drug use 20 . Bearing in mind that the population of this research is eminently young and that it is in this period that the first emotional disorder symptoms are manifested, these students are considered more vulnerable to behaviors associated with risks, mainly the use of drugs 38 . The Questionnaire of socioeconomic-demographic characteristics found that 83.9% of the students affirmed that they used alcohol and 8.2% that they used illicit drugs. This study did not have as main objective to approach this issue, but we considered this situation a reason for concern. Studies indicate that there is a worldwide tendency to increased use of drugs, particularly in the university atmosphere 39 and that students of Medicine feel less vulnerable to the harm done by such substances 40 . In this manner we believe Depressive and anxiety symptoms in medical students that the theme deserves to be investigated in future studies, for possible preventive measures to these risk factors.
Finally, another issue to be considered is suicide. Research points out that 95% of the persons that commit suicide are diagnosed with psychiatric disorders and that the main significant factors for suicidal thoughts are anxiety and depression 26,30 . It is important to emphasize that the risk exists and should be regarded with the gravity it deserves.

CONCLusION
The high prevalence of depressive and anxiety symptoms in medical students is possibly connected with stressful factors inherent to academic training, associated with psychodynamic characteristics. Some of the students, as a consequence of their own personality traits, demonstrate more acute emotional distress and greater difficulties to face conflictive issues, becoming more vulnerable to emotional disorders and consequently to risk situations. Issues attributed to the medical career may, in truth, be related to experiences preceding the university period. In this context are involved intrinsic and extrinsic aspects, that may influence the performance of the student, affecting his personal, family and professional life.

INDIVIDuAL CONTRIbuTIONs
Rosana Denobile serra -Data collection and writing.