Depressive symptoms in medical students of Universidade Federal de Goiás: a prevalence study

Abstracts

INTRODUCTION: The objective of the present study was to assess the prevalence of depressive symptoms among medical students of Universidade Federal de Goiás, Brazil, comparing them to the general population and investigating the possibility of a certain period throughout the course being a risk factor. METHOD: A cross-sectional descriptive study of a representative sample of students regularly enrolled at the Medical School of Universidade Federal de Goiás was performed. A total of 287 students from the first to sixth year were selected using simple random drawing. The Beck Depression Inventory and an identification questionnaire were used for evaluation. RESULTS: In the interviewed population, 26.8% had depressive symptoms according to the Beck Depression Inventory scores established for this study. The prevalence of moderate and severe depressive symptoms among the interviewees was 6.9%, while 19.9% had mild symptoms. As to gender, 33.5% of the women and 19% of the men had depressive symptoms. There was higher prevalence between third- and fourth-year students. Sadness, anhedonia, low self-esteem, perfectionism, irritability, lack of interest for people, reduced work capacity, and excessive tiredness were the most punctuated items of the Beck Depression Inventory. CONCLUSION: The prevalence of depressive symptoms found in this study is higher than the average found in the general population, and there is an indication that the medical school can be one of the predisposing factors for these symptoms.

Medical students; depression; prevalence; prevention

INTRODUÇÃO: O presente estudo teve como objetivo investigar a prevalência de sintomas depressivos em alunos de medicina da Universidade Federal de Goiás, comparando com a população em geral e verificando a possibilidade de determinado período do curso atuar como fator de risco. MÉTODO: Estudo transversal, descritivo, de amostra representativa de alunos regularmente matriculados na Faculdade de Medicina da Universidade Federal de Goiás. Foram selecionados 287 alunos do primeiro ao sexto ano através de sorteio aleatório simples. Utilizou-se, para avaliação, o Inventário de Depressão de Beck e um questionário de identificação. RESULTADOS: Na população entrevistada, 26,8% apresentaram sintomas depressivos de acordo com escores do Inventário de Depressão de Beck estabelecidos para este estudo. A prevalência de sintomas depressivos moderados e graves entre os entrevistados foi de 6,9%, enquanto 19,9% apresentaram sintomas leves. Em relação ao sexo, encontrou-se 33,5% de mulheres e 19% de homens com sintomas depressivos. Em relação ao ano em curso, houve maior prevalência entre os alunos do terceiro e do quarto ano. Tristeza, anedonia, baixa auto-estima, perfeccionismo, irritabilidade, desinteresse por pessoas, redução da capacidade de trabalho e cansaço excessivo foram os itens do Inventário de Depressão de Beck mais pontuados. CONCLUSÃO: A prevalência de sintomas depressivos encontrada neste estudo é superior à média encontrada na população em geral, havendo indicativo de que a escola médica possa ser um fator predisponente para tais sintomas.

Acadêmicos de medicina; depressão; prevalência; prevenção

en_v30n2a08

ORIGINAL ARTICLE

Depressive symptoms in medical students of Universidade Federal de Goiás: a prevalence study

Geraldo Francisco do Amaral^I; Lidyane Marque de Paula Gomide^II; Mariana de Paiva Batista^II; Paulo de Paula Piccolo^II; Thais Bittencourt Gonsalves Teles^II; Paulo Maurício de Oliveira^III; Maria Amélia Dias Pereira^IV

^IPhD in Health Sciences, Universidade de Brasília (UnB), Brasília, DF, Brazil. Associate professor and coordinator, Medical Psychology, Department of Mental Health and Forensic Medicine, Faculdade de Medicina, Universidade Federal de Goiás (UFG), Goiânia, GO, Brazil. Coordinator, CENTROHUMOR - Centro de Referência em Transtornos do Humor, Hospital das Clínicas, UFG.

^IIMedical student, Faculdade de Medicina, UFG.

^IIIMSc in Health Sciences, UnB. Collaborative professor, Medical Psychology, Department of Mental Health and Forensic Medicine, Faculdade de Medicina, UFG. Consultant, Psychiatric Interconsultation Service, Hospital das Clínicas, UFG.

^IVMSc in Psychiatry, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil. Associate professor, Medical Psychology, Department of Mental Health and Forensic Medicine, Faculdade de Medicina, UFG. Coordinator, Medical Student Support Center, UFG.

Correspondence

ABSTRACT

INTRODUCTION: The objective of the present study was to assess the prevalence of depressive symptoms among medical students of Universidade Federal de Goiás, Brazil, comparing them to the general population and investigating the possibility of a certain period throughout the course being a risk factor.

METHOD: A cross-sectional descriptive study of a representative sample of students regularly enrolled at the Medical School of Universidade Federal de Goiás was performed. A total of 287 students from the first to sixth year were selected using simple random drawing. The Beck Depression Inventory and an identification questionnaire were used for evaluation.

RESULTS: In the interviewed population, 26.8% had depressive symptoms according to the Beck Depression Inventory scores established for this study. The prevalence of moderate and severe depressive symptoms among the interviewees was 6.9%, while 19.9% had mild symptoms. As to gender, 33.5% of the women and 19% of the men had depressive symptoms. There was higher prevalence between third- and fourth-year students. Sadness, anhedonia, low self-esteem, perfectionism, irritability, lack of interest for people, reduced work capacity, and excessive tiredness were the most punctuated items of the Beck Depression Inventory.

CONCLUSIONS: The prevalence of depressive symptoms found in this study is higher than the average found in the general population, and there is an indication that the medical school can be one of the predisposing factors for these symptoms..

Keywords: Medical students, depression, prevalence, prevention.

INTRODUCTION

Medical students are often exposed to stressful situations, which may contribute to the development of several pathological processes, both physical and psychic. Studies relating occurrence of depressive symptoms in this group of college students have shown a high prevalence of these symptoms when compared with the general population. Such high prevalence may be associated with a number of factors inherent to medical school and to individuals themselves.^1-3

Research has shown that the prevalence of depressive symptoms/disorders in this population is estimated between 8-49%, and this variation seems to be due to methodological flaws and because of varied instruments used in the studies.⁴ Cavestro & Rocha,⁴ using the Mini International Neuropsychiatric Interview (MINI), a standardized diagnostic interview for axis I disorders, found an 8.9% prevalence rate of major depressive disorder (MDD) in medical students at Universidade Federal de Minas Gerais (UFMG).

In a study on first-year medical students, Parkerson et al.⁵ observed worsening in all parameters related to health and personal satisfaction throughout the year, and the most remarkable variable was increase in depressive symptoms. Demand for a perfectionism found in medical students, when compared with students of other college courses, expressed in a neuroticism and permanent stress symptoms, is considered by Enns et al.¹ as predictive of depression and hopelessness. Rosal et al.⁶ also concluded that increased levels of depression symptoms and their persistence suggest that emotional stress during medical school is chronic and non-episodic. However, among the diseases developed by medical students depression is one of the least detected and treated.⁷

In another study, De Armond⁸ found loss of personal freedom, excess of academic pressure, feeling of dehumanization, lack of time for leisure, marked competition between colleagues and frequent contact with sick people as academic environment conditions that make it a predisposing factor to occurrence of depressive symptoms.

Such situations are currently corroborated by recent studies,^9,10 which identified a similar condition worsened by increased use of illicit drugs, considering that prevention groups are the only form of resolute service. Merrit et al.¹⁰ pointed out that college students participating in intervention groups on "depression" improve identification of symptoms and treatment by acquired knowledge, especially in relation to antidepressants not causing dependence.

Psychodynamic characteristics are attributed to medical students. Along with environmental factors, they are considered as possible triggering agents of emotional and psychiatric disorders.^11,12

Certain periods during medical school are seen as more favorable to the development of disorders. In our country, a study by Nader & Barros¹³ showed a significant increase in depressive symptoms between the first and seventh semester, whereas Porcu et al.² found higher prevalence in the transition between the second and third year, passing from preclinical to clinical period.

In a meta-analysis study, Lloyd & Gartrell¹⁴ showed that between 4-14% of medical students search psychiatric help throughout the course. Suicide is the second cause of death among medical students, secondary only to accidents.¹⁵ Students with better school performance have higher risks of suicide.^16,17 Since these students are excessively self-demanding and are constantly in contact with patients with varied prognoses and life experiences, feelings of depreciation and impotence before any failure may account for ideas of course dropout, depression and suicide.^18,19 In addition, studies indicate that prevalence of depression in females is twice higher than in men in this academic population.¹⁶

Although the objective of medical schools is to form professionals with knowledge and skills, some aspects of this formation have been pointed as the cause of negative effects on students' mental and physical health,²⁰ even considering that psychiatric morbidity in the family, life experiences and personality are etiological factors more important than occupational factors.²¹

Despite the confidentiality of mental health services offered by medical schools, students with depression are rarely treated, whether due to stigma, lack of symptom identification or non-acceptance of the disease.^7,9,10,16

This article describes a study that identifies prevalence of depressive symptoms in medical students at Universidade Federal de Goiás (UFG) and possible contributing factors for the development of these symptoms. It was conducted at the Medical Psychology course of the Department of Mental Health and Forensic Medicine at Faculdade de Medicina (UFG).

The present study aimed to investigate the prevalence of depressive symptoms in medical students at UFG, identifying them according to course year, comparing with the general population and verifying the possibility a certain course period has of acting as risk factor for the development of these symptoms.

Students identified with high scores of depressive symptoms will be referred for specialized evaluation. Results may be useful for the creation of coping and prevention strategies.

METHOD

Ethical aspects

The protocol was reviewed and approved by the Ethics and Human Medical and Animal Research Committee (CEPMHA) at Hospital das Clínicas, UFG.

Design

A cross-sectional descriptive study of a representative sample of students regularly enrolled at the Medical School of UFG.

Sample characterization

Using finite sample calculation (universe of 660 students) and 5% margin of error, a final sample of 243 students was obtained.

Simple random drawing was used in the students enrolled at the Medical School of UFG, divided by year. A total of 287 students were interviewed; exclusion criteria were not consenting to participate or not being found. According to year the sample was characterized as follows: first year: 54 students; second year: 57 students; third year: 58 students; fourth year: 52 students; fifth year: 40 students; sixth year: 26 students.

No students refused to participate in the study. Only 26 sixth-year students were interviewed, and the others were not found within the time allocated for data collection because they were interns in varied locations and there were also rural interns. As a result of such reduction, a specific analysis was performed aiming to evaluate existence of difference between sixth-year students with depressive symptoms and students in other years, and there was no significant difference (p = 0.922). Such reduction does not imply compromise of results.

Data collection procedures

Data collection was in June and July 2006, at classrooms, after instructions on the research were provided and the students signed a consent term validated by CEPMHA of Hospital das Clínicas, UFG.

Evaluation instrument

The Beck Depression Inventory (BDI) was used, a symptomatic scale to screen depression, self-administered, comprised of 21 items evaluating depressive symptoms present in the past week. The BDI was validated in Brazilian clinical and population samples by Gorenstein & Andrade²² in 1996 and by Cunha²³ in 2001. This study considered the following scores: 0 to 9 (absence or minor depression), 10 to 16 (mild depression), 17 to 29 (moderate depression), 30 to 63 (severe depression).

An identification questionnaire with the following variables was also used: name, marital status, age, gender, paid activity, and course year. The following close-ended questions were asked: "Who do you live with? (parents/siblings, relatives, friends, alone);" "Have you ever undergone treatment for depression? (no; yes, I have);" and "Are you under treatment for depression? (yes/no)."

Data analysis procedures

Kruskal-Wallis, chi-square and variance analysis tests were used for analysis and comparison of results, using the SPSS 15.0 software and a 95% confidence interval. Absolute and relative frequencies, mean and standard deviation were used to describe the variables.

RESULTS

The sample was comprised of 287 individuals with mean age of 21.3 years. Distribution between men and women was 45.7 and 54.3%, respectively, and only three were married. Some type of paid activity was reported by 11.2%; 7% did not report it. In terms of housing, 71.8% live with their family (parents, siblings); 5.3% with relatives (grandparents or uncles); 11.5% live in dormitories; 6.3% live alone; and 5.3% did not report it. Among the interviewees, 79.8% stated never having diagnosed depression and/or undergoing treatment for it, whereas 8.1% reported having had/undergone it before entering medical school, and 7% stated having gone through the pathological process after entering medical school. In addition, 6.3% admitted being under treatment during the research period. In the interviewed population, 26.8% had depressive symptoms according to the BDI scores established for this study (Table 1).

The prevalence of moderate and severe depressive symptoms among the interviewees was 6.9%, while 19.9% had mild symptoms. Depressive symptoms were not present in 73.2% of the sample. As to gender, there were 7.7% of women and 6.1% of men with moderate and severe depressive symptoms, while 25.8% of women and 12.9% of men had mild depressive symptoms. Depressive symptoms were not present in 66.5% of women and 81.1% of men. In this study mean score for depressive symptoms in male individuals was 5.39±5.30 and 8.46±7.00 in female individuals, with significant difference (p < 0.001).

There was no significant difference (p = 0.803) in mean scores between students having paid activity (mean 8.09±5.34) and those exclusively dedicated to the course (7.02±6.57). There was also no significant difference between students living with their family and those not living in a family environment (p = 0.733)

There was significant difference in relation to treatment for depression (p < 0.001) in terms of scores found between students that were never treated (mean 5.9±5.2), those that were treated before entering medical school (mean 11.8±7.1) and students that were treated after entering medical school (mean 15.3±10.4). Among students under treatment (16.50±11.10), mean BDI score was significantly higher when compared with those that reported not being under treatment (6.41±5.48) (p < 0.001)

As to prevalence of depressive symptoms in relation to course year, there was higher frequency among third- and fourth-year students, and significant difference between those that had some type of depressive symptom and those that did not have these symptoms (p < 0.001) (Figure 1).

Results for each BDI question were also analyzed, aiming to find a prevalent symptom among individuals of this population group. Therefore, 28.9% of students reported feeling sad, and 67.6% feel somehow worse than the others (item 8 of BDI). As to item 11, 50.7% of them were more annoyed during the research period than those that already were. As to item 12, 38.8% somehow lost interest for other people; and in item 15, 46% reported having lost their ability to work as well as before. Getting tired more easily than usual was reported by 61.2% (item 17).

DISCUSSION

In general, college students are a reason of concern as to presence of depressive symptoms. Studies have been conducted in specific units²⁴ and comparing different courses with medical school.^1,4,10,25

However, such concern does not reflect into objective strategies to fight pathological situations as there are few publications of results on this issue, when compared with the number of studies aiming to detect symptoms or disorders, especially depressive.^26-29

The percentage of depressive symptoms found in this study (26.8%) is below that found by Porcu et al.² (49.2%) and Moro et al.²⁵ (40.7%), although the same verification instrument has been used (BDI). For Porcu et al.,¹ the difference seems to lie on the parameters used by the authors, who considered the following cut-off points for depression: mild (4-7); moderate (8-15); and severe (over 16). In the study by Moro et al.,²⁵ the parameters used were similar to those used in this study and were in accordance with studies using a cut-off point ? ¹⁷ as major depression.³⁰ Our data are also similar to other studies in percentage terms.^6,7,26,31,32

The study conducted by Cavestro & Rocha,⁴ using a structured interview for diagnosis, found 8.9% of major depression in medical students. Considering the study by Sprinkle et al.,³¹ which found a correlation between MDD and cut-off point over 17 in the BDI, the 7.3% rate of moderate and severe symptoms found in this study can be considered important.

Our data showed a higher percentage of women with depressive symptoms - 33.5 vs. 19% of men - which is in agreement with what has been found in other studies and in the general population.^2,6,17,25,26

These results, as previously reported by Rosal et al.,⁶ suggest that presence of depressive symptoms and stressful situations is more chronic and persistent than the episodic depression, and this is more significant in females.

When stratifying according to course year, there was higher prevalence from the second to the third and fourth year. Some factors identified in other studies were also present, such as going to hospitals, with a closer contact with severe patients and death; high demand from theoretical and practical courses, which requires a higher number of study hours; fatigue; demand to participate in extracurricular medical activities, such as academic leagues; disputes between students for better positions in services or academic activities.^{1,2,6,17,18,25,26,32} Reduced prevalence rate from the fourth to the fifth year and a slight exacerbation in the sixth year seems to be in accordance with the anxiety of ending the course and preparation for the medical residence test, simultaneously with intern work. A qualitative study on stressful factors and quality of life performed by Pereira et al.³³ in medical students at UFG showed that the quality index is worse than that found in the general population and that this index significantly worsens in female students of all years and in both genders in the third and fourth year. This fact seems to be in accordance with the result found in this study as to higher prevalence of depressive symptoms in third- and fourth-year students.

Also in accordance with Givens & Tjia⁷ and Nuzzarelo & Goldberg,³⁴ it can be perceived that medical students are reluctant to seek proper psychiatric treatment, which is likely due to fear of stigma, confidentiality, costs. A student's statement published by Rosenthal & Okie²⁶ is interesting: "...If I'm going to be a doctor, I've got to be well." In this investigation, this seems to be confirmed as only a small percentage sought help, despite the prevalence found.

The most expressive BDI scores in this study were observed in the affective cognitive subscale and in the performance subscale, as described in the results.

The fact that 7.9% of students already had plans about committing suicide (item 9) is important, although this is not one of the objectives of this research (evaluating suicidal behavior), but other studies also show this concern, since they found a higher percentage of suicidal tendency in medical students than in the general community.^4,7,17,26

These results should encourage offer and/or improvement of student service regarding both therapeutics and prevention. In a study on this theme, Stecker⁷ and Merrit et al.¹⁰ considered that nowadays students are strongly exposed to stress, sleep and appetite changes, lack of physical exercises, risk sexual behavior, use of substances and depression, and that creation of groups with such focus (pharmacological and psychological treatment) can be an important method to reduce frequency and severity of these symptoms.

Early detection of risk groups and identification of difficulties experienced by students along each course year may indicate the need of developing coping and prevention strategies. This can be performed through continuous psychoeducation projects that sensitize students for the risks that psychic disorders and professional dysfunctions may bring to the well-being of themselves, their relatives and patients.

At the Medical School of UFG and at the university as a whole, the Medical Student Support Center (NAEM) and the Healthy Program provide permanent service to the students of all units with risk behaviors and/or psychic suffering, although at an insufficient level due to lack of proper facilities and few professionals.³⁵

One limitation of this study is not using a structured interview to confirm the results found by the BDI and the fact that cross-sectional studies only provide a momentary view of the investigated population.

CONCLUSIONS

Prevalence of depressive symptoms found in medical students at UFG in this study is higher than the average found in the general population. As in other studies, there is an indication that the medical school can be one of the predisposing factors for these symptoms and their consequences. Creation and improvement of strategic programs for student support at a pharmacological and psychological level are important. In addition, students should be continuously informed of the possibilities of developing such symptoms. Further longitudinal follow-up studies should be conducted.

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Publication Dates

• Publication in this collection
  06 Jan 2009
• Date of issue
  Aug 2008

History

• Received
  11 Feb 2008
• Accepted
  07 May 2008