Depressive symptoms among healthcare undergraduate students

Objective: to identify the intensity of depressive symptoms and their associated factors in healthcare undergraduate students. Method: cross-sectional study developed with undergraduate health students from a public higher education institution using the Beck Depression Inventory-version II and a student characterization questionnaire. The study involved 792 participants. For data analysis, we used descriptive statistics, chi-squared test and Poisson regression. Results: the intensity of depressive symptoms was moderate to severe in 23.6% of the students, associated with the non-performance of physical and leisure activities and with speech therapy and nursing courses. Conclusion: several factors may be associated with depression, thus, further investigation into the related factors that cause its emergence in this period of life is necessary, as well as raising institutional awareness and developing strategies at the personal and group level to promote well-being, improve time management and interpersonal relationships, in order to achieve better academic results and personal development.

to switch undergraduate courses, difficulties in social relationships and evaluating the teaching environment as an environment with many problems (8) . The study also pointed other predictors of depressive symptoms in college students: sex, basal depression, neuroticism or psychoticism, automatic negative thoughts or obsessive negative rumination, dysfunctional attitude, childhood abuse, sexual abuse and stressful life events (10) .
Given the data presented, it is important to consider the onset of depressive symptoms in higher education students in order to find coping strategies for reducing the suffering and anguish that this period may cause, as well as for preventing these future professionals from entering working life already sick.
Importantly, there is a gap in knowledge on depression in healthcare undergraduate students. We searched the Virtual Health Library (VHL), using the descriptors "estudantes de ciências da saúde" (health sciences students) and "depressão" (depression), between 2012 and 2016. We initially found 16  Index on Health Sciences). Of these studies, six did not involve healthcare students (11)(12)(13)(14)(15)(16) , six had another topic as their study focus (17)(18)(19)(20)(21)(22) and two analyzed only one healthcare course (23)(24) . Only one study evaluated four healthcare courses, but was conducted in Saudi Arabia (25) . Thus, we found no Brazilian study evaluating depressive symptoms in undergraduate students in all healthcare courses.
The present study, therefore, was guided by the research question: What is the intensity of depressive symptoms and their associated factors in healthcare undergraduate students? Our objective in this study was to identify the intensity of depressive symptoms and their associated factors in healthcare undergraduate students.

Method
This is a cross-sectional study, conducted at a public university in the interior of the state of Rio  (29) . In addition, the total average score of the instrument was calculated.
We also used a questionnaire to characterize the students' profile through sociodemographic variables
Regarding the individual items of the scale, we describe those with the highest prevalence, showing which are the symptoms that most stood out among the students. We found that 35 (4.4%) of the students blamed themselves for everything bad that happened; 93 (11.7%) had difficulty making any decision; 38 (4.8%) had changes in their sleep pattern, that is, they slept most of the day or woke up an hour or two earlier and could not sleep again. Regarding irritability, 44 (5.6%) said they were angry all the time, 49 (6.2%) had no appetite or wanted to eat all the time and 55 (6.9%) felt too tired to do most of the things they used to do.  Rev. Latino-Am. Enfermagem 2020;28:e3239. and health habits -, we found that students that did not perform physical activities did not have time for leisure, and that those who attended speech therapy and nursing showed a higher prevalence of depressive symptoms.

Discussion
The overall prevalence of common symptoms of depression was moderate to severe in 23.6% of the students. A meta-analysis of 39 studies from 1997 to 2015, involving more than 32,000 Chinese university students, identified a global prevalence of depression of 23.8%, which was higher among medical students (30) .
When considering health services, a systematic review of the national academic production highlighted the prevalence of depression in health workers between 15.4% and 40.5%, with higher scores among professionals working in higher risk areas and/or working in shifts (31) .
In this sense, we can observe that depression occurs in students and health workers. In this case, undergraduate students have presented difficulties of a different order, which may involve adaptation to the university context, distancing from family and friends, financial difficulties and identification with the course.
In addition, in practical activities, students have greater daily proximity to diseases, death and terminality, experiencing socioeconomic difficulties of the population and the difficulties encountered in health services (32) . Symptoms such as pessimism, sadness, crying, selfcriticism and irritability should also serve as a warning, but often go unnoticed in the academic environment (33) .
In this sense, it should be considered that depression is multifactorial, involving genetic as well as environmental factors in its pathophysiology. In some cases, genetic aspects seem to be predominant (presence of several affected members in the family); in others, environmental, social, economic and relational aspects seem to play a relevant role, as well as the ability to manage these factors (34) .
Among the aspects that may influence the development of common symptoms of depression in undergraduate students are social, economic, academic and health habits factors. In this sense, we identified associations of common symptoms of depression with female students, obese students, those who had a medical condition diagnosed by a doctor, those who used bus as a means of transport, those who did not perform physical activity, those who did not have leisure activities, and with the courses of Speech Therapy and Nursing. After performing a regression analysis grouping these variables, we identified students who Bresolin JZ, Dalmolin GL, Vasconcellos SJL, Barlem ELD, Andolhe R, Magnago TSBS.
did not perform physical activity, did not have time for leisure and attended speech therapy or nursing courses, whose prevalence rates of depressive symptoms were 12%, 20%, 14% and 10% higher, respectively.
Among medical students from the state of Ceará, those who performed physical activities sporadically or rarely were, respectively, 2.45 times and 3.04 times more likely to develop depression, compared with those who regularly engaged in physical activities. Enjoying leisure activities and having good social relationships with friends and family seems to be good for students' mental health (35) . Thus, this shows that not having healthy lifestyle habits, with time for physical activities and leisure, is detrimental to students' mental and physical health.
The course that presented the highest prevalence of depression was speech therapy, a result that may be associated with its high course load. Speech therapy students from Ceará also reported feelings of anxiety, frustration, insecurity, inability, anguish, sadness, fear and negative feelings, especially while initiating the course (36) . The Nursing course also presented a high prevalence of depression, which demonstrates that the course load, the student's insertion in the hospital environment and the thoughts regarding the professional future can cause these students to develop psychic disorders (37) .
The required classroom hours and the academic activities, such as study routines and work assignments, which need to be done outside the classroom may overload the student (38) . Therefore, it is important to consider that physical inactivity, along with lifestyle and anxiety and depression levels are risk factors for the onset or aggravation of various diseases, especially chronic degenerative diseases (39) . Students with certain personality traits who cannot maintain a balanced routine of academic and personal activities remain more isolated, anxious and develop eating disorders leading to excessive weight gain or loss. Thus, the student's mental health is compromised, which may cause the onset of disorders such as depression. Among US students, the variables that stood out for stress, anxiety and depression were the pressure for academic performance, professional success and plans to pursue graduate studies; and most of them were transfer students who lived outside of the university campus (40) .

As for the variables identified in association with
depression, women showed a prevalence of moderate/ severe depression of 25.9%, and in gross regression showed a prevalence 7% higher compared with males.
This may be associated with the fact that women reach physical and emotional maturity earlier, thus facing the challenges with more responsibility and commitment, compared with males. Concerns begin to emerge in undergraduate studies, as it is a decisive period that will define both one's professional and personal future (41) .
We also found that students who used bus as a means of transportation to the university showed a prevalence of moderate/severe depression of 27.4%; and compared with those using other means, they showed a 6% higher prevalence. This may be associated with the need to wake up earlier, commuting alone through empty streets, urban violence, overcrowding at peak times, longer commuting times, and more. Bus users also report dissatisfaction; discomfort and stress with the always-packed buses; intolerable waiting time; lack of commitment and education of bus drivers; and lack of a pleasant structure (42)(43) .
The identification of variables associated with depression among university students allows the development of strategies to prevent and promote their psychic health. With this, the process of teaching/ learning can be optimized.
As limitations of the study, we highlight the difficulty of access and low response rates of students who were in the internship period, because they were not attending classroom activities in the teaching unit, but were working in health service units, both in the municipality itself and in others cities, sometimes out of the state.
However, to minimize this limitation, these students were invited to participate by e-mail, responding online to the instrument through an electronic form.

Conclusion
The intensity of common symptoms of depression ranged from moderate to severe in 23.6% of undergraduate health students. The courses with the highest prevalence of common symptoms of moderate to severe depression were Speech Therapy (47.6%) and Nursing (34.2%).
Regarding the variables associated with common symptoms of depression, those who did not perform physical activities, had no leisure time and attended speech therapy and nursing courses showed a higher prevalence of symptoms. In addition to these, we identified an association with females, using bus as a means of transport, having some medical diagnosis, making use of medication and being obese.