PREVALENCE OF DEPRESSION AMONG MEDICAL STUDENTS AT AL-AZHAR UNIVERSITY: A CROSS SECTIONAL STUDY

PREVALENCE OF DEPRESSION AMONG MEDICAL STUDENTS AT AL-AZHAR UNIVERSITY: A CROSS SECTIONAL STUDY

By

Alaa Abdelwahed Shams-Eldin, Haytham Hassan, Soliman Amer*, and Khaled Kasim

Department of Community Medicine, Faculty of Medicine (Cairo and Damietta*), Al-Azhar University

ABSTRACT

Background: Depression among medical students may promote development of physical and mental problems. Few studies investigated its prevalence among medical students in Egypt.

Objective: This study aimed to determine the prevalence of depression and to identify some related risk factors among Al-Azhar University medical students, Cairo, Egypt.

Subjects and Methods: A cross-sectional study was conducted at Faculty of Medicine (Boys and Girls), Al-Azhar University, Cairo, Egypt. A cluster sample was taken and included students from all study years. A self-administered questionnaire was completed to 1254 students from January to March 2017. Data concerning socio-demographic and lifestyle and sleeping related factors were collected using a valid self-administered structured questionnaire including PQ-2 instrument for depression screening. The prevalence of depression was estimated, and appropriate statistical analyses were performed to compare the prevalence of depression by the studied students' factors.

Results: The overall prevalence of depression was 42.9%. The prevalence was significantly high among females (46.4%), early study years (48.4%), and those living away from family. Students reported frequent fast food intake, watching TV and use social media, not in touch with their friends, and those eating one meal per day also showed significant high prevalence. Sleeping related factors appeared to influence the prevalence of depression among the studied students where prevalence was high among those reported less sleeping hours, use of sleeping medications and those spent > 2 hours in bed before sleeping.

Conclusion: A high prevalence of depression among the studied medical students was detected. The study suggested a variety of risk factors and the need of psychiatric counseling and support services available to vulnerable students.

Key words: Al-Azhar, Depression, Lifestyle, Medical students, Prevalence.

INTRODUCTION

     Psychological and mental health problems among university students are considered one of the vital and escalating public health problem worldwide, for which epidemiological data is required and should be addressed as a priority problem (Eisenberg et al., 2013). Medical education is among the most challenging and stressful ones. High level of stress may have a negative effect on cognitive functioning and learning of students in the medical school (Mancevska et al., 2015).

     The studies conducted on medical students in Egypt as well as in different regional countries have shown that medical students have high rates of anxiety and depression during their years of studying and training. In Egypt, a cross-sectional study was carried out on 164 medical students and 164 pharmacy students at Alexandria University. The study reported the prevalence of anxiety and depression among medical students to be 43.9% and 57.9%.

     It is recommended to conduct psychological and mental screening of medical students (Mancevska et al., 2015). As anxiety and depression represent the most important health related problems among medical students (Eisenberg et al., 2013), and as there are great lack of data about the prevalence of these problems among medical students in Egypt, there would be a need to conduct epidemiological study to assess the magnitude of this fundamental problem among medical students at the Egyptian Universities.

     The present study aimed to determine prevalence of depression and some related risk factors among male and female medical students at Al-Azhar University, Cairo, Egypt. 

SUBJECTS AND METHODS

     A cross section study was conducted to determine the prevalence of depression among medical students at Al-Azhar University, Cairo, Egypt during the study year 2016/17.

     A cluster sampling procedure was used where only group was randomly chosen from each study year in the studied Faculty of Medicine (boys and girls). All students from the chosen group in each study year were invited to complete self-administered, anonymous questionnaire during the period from January through March 2017.

     The questionnaire was designed by the research team and it was based on PQ-2 for depression screening questions (Löwe et al., 2010 and Maurer, 2012). The questionnaire has also included socio-demographic factors and data related to dietary habit and other lifestyle factors. Sleeping related variables and associated chronic medical problems were also included in the study questionnaire. The PQ-2 is an ultra-short screening instrument, including simple questions inquiring about the frequency of depressed mode over the past two weeks, and include only the first two items from PHQ-9. The questions were as follow: over the past 2 weeks, how often have you bothered by any of the following statements; i) little interest or pleasure in doing things, ii) Feeling down, depressed or hopeless. The PQ-2 score ranges from 0-6 where score 0 indicates "not at all", score 1 "Several days", 2 "more than half the days", 3 "nearly every day".  The cutoff score of 3 was used as the optimal cutoff point in this study for screening purpose. It is mentioned that cutoff score of 3 would enhances the sensitivity of PQ-2 questionnaire and improves its specificity (Löwe et al., 2010 and Maurer, 2012). The validity of other variables included in the study questionnaire was tested by a psychiatrist and an epidemiologist.

     The calculated sample size of this study was 1230 students based on the average estimated depression prevalence among medical students in the previous Egyptian studies (54%) done in the Faculty of Medicine, Alexandria University (Ibrahim and Abdelreheem, 2015), an assumed precision of 3% and a confidence interval of 95%.

     All students at the Faculty of Medicine (boys and girls) were eligible to participate in this study during the study year 2016/17. The questionnaires were completed and returned back by 1254 students (623 male students and 631 female students). The back‌ground and purpose of the study were explained at the beginning of the questionnaire.

     The participation of students was voluntary, and ethical considerations were also considered to ensure confidentiality and privacy of the collected data. Finally, approval was taken from the ethics committee at Al-Azhar Faculty of Medicine.

     Statistical analysis: The collected data were entered and analyzed susing SPSS package (version 22.0). Data were presented using frequencies and percentages. The prevalence of depression among the studied students was assessed. The prevalence of depression was then compared by all studied students’ characteristics using chi square test. The analysis for the last year academic grades were done for only 1056 students as students of the first year were not included. P values ≤ 0.05 were used as indicators of statistical significance differences between students according to their characteristics.

RESULTS

     The overall prevalence rate of depression among the studied 1254 medical students at Al-Azhar University was 42.9%. The depression was significantly more prevalent among female students (46.4% among females vs. 39.5% among males). The prevalence of depression was significantly higher among basic sciences level students (2nd and 3rd study years) compared to clinical sciences level students (4th, 5th and 6th study years) where the prevalence was 48.4% and 36.8%, respectively. A significant low level of depression, however, was found among students who were living with their family (30.3%) compared to those living in University residence (44.2%) and outside residence but without their families (44.8%) (table 1).

Table (1): Prevalence of depression by socio-demographic data of the studied medical students

Data were presented as number and % (in between brackets)

     There were no statistically significant differences between depressed and non-depressed students in matters of smoking status and physical activity practice, although the prevalence of depression was slightly higher among smokers and those with no or less physical activity practice. On the other hand, however, there were statistically significant differences regarding the number of weekly and daily number of meals where the higher proportion of the depressed students was among those reported eating more than 5 fast food per week (52.9%) and to eat only one food meal per day (57.6%). No keeping in touch with friends outside medical school showed a significant high prevalence of depression among the studied students (53.3%). Frequent time spent in watching TV and social media showed significantly high prevalence of depression among the studied students. The prevalence of depression among the studied students showed non significant variations by their body mass index. The prevalence of depression was 42.6% and 42.5% among normal weight and overweight students respectively, while it was slightly higher (48.9%) among obese students (table 2).

Table (2): Comparison between depressed and non-depressed students according to life-style factors

Data were presented as number and % (in between brackets)

     The prevalence of depression showed statistically significant difference by sleeping duration a day where the prevalence was 47.1% and 48.2% among students reported to sleep < 6 hours and > 8 hours a day, respectively. Time spent in bed before sleeping was also showed significant high depression prevalence among report to spend more than 2 hours (52.2%). Students reported to often taking sleeping medications showed a non significant high depression prevalence of depression of 52.2% (Table 3).

Table (3): Comparison between depressed and non-depressed students according to sleep related factors

Data were presented as number and % (in between brackets)

     The study hours per day and study state did not show significant differences in the prevalence of depression among the studied students, although the depression prevalence was lower among those reported to study less than two hours a day (39.1%) and those studying all the time in a group (28.5%). The students reported that study limits social life activity showed significantly higher depression prevalence (48.3%) than those reported that medical study does not affect social life (34.1%). The academic grades showed none significant variation in the prevalence of depression among the studied students where the prevalence of depression was found to be high among students with high (very good and excellent) and low (acceptable), and to be slightly low among students with good academic grade (36.5%) (table 4).

Table (4): Comparison between depressed and non-depressed students according to study related factors

Data were presented as number and % (in between brackets)

*The analyses were done for only 1056 students as students of the 1st year were not included

DISCUSSION

     The present study revealed a high prevalence of depression among medical students at Al-Azhar University in Cairo, Egypt. The estimated prevalence was 42.9% (95% CI= 40.3%-45.7%). The higher prevalence of depression among medical students has been explained by several theories in many researches, e.g. some have contributed these findings to that medical students pass through continuous examinations throughout their academic years. Studying medicine is competitive. Several academic stressors were reported in many previous researches (Abdulghani et al., 2011; Abdel Rahman et al., 2013 and Ibrahim and Abdelreheem, 2015).

     Regarding the prevalence of depression among medical students in this study showed significant variations by sex, study years and residence of the students. The prevalence was significantly high among female students (46.4%), basic sciences study year students (48.4%), among students who reported living in university residence (44.2%), outside the university residence (44.8%), and away from their families (30.3%). This result agreed with studies by Ibrahim and Abdelreheem, (2015) in Alexandria who found that the prevalence of depression and stress was higher among the female students. Also,  in a cross-sectional study conducted on 450 female medical students in King Abdulaziz University, Jeddah, Saudi Arabia, the prevalence of depression was 36.5%; while 21.8% and 14.7% had a border-line and morbid depression, respectively (Ibrahim et al., 2013).

     The study results revealed that students away from their family (in and outside the University residence) were found to have had a significant high prevalence of depression. These findings appeared consistent with the results of South Korean study reported high depression prevalence among students living alone at a lodging house or a rented room , unmarried students, and among students with financial difficulty (Myoung-Sun and Sung, 2010).

     The level of depression in this study was found to increase among students in the second and third years of the medical course (basic sciences course). Among these students the prevalence was 48.4% compared to only 36.8% among clinical sciences study years students. These findings agree with a study conducted by (Maurer, 2012).

     The comparison of depression prevalence among medical students in this study by their lifestyle characteristics showed significant variations for some studied factors. The prevalence was significantly high among students reported frequent weekly intake of fast food for > 5 times (52.9%), eating only one meal per day where the (50.0%), among those watching TV and/or on social media for > 4 hours a day (50.7%), and among those never kept in touch with friends outside medical school (53.3%). Consistent with these findings, bad dietary habits, were found in many studies to be associated with increased risk of mental and psychological disturbance, particularly among adolescents (Guilbeau, 2012 and Sepkowitz, 2013). Also, the prevalence of depression in this study was higher among smokers (44.4%) and obese students (48.9%), although not significant. These findings contributed to the evidence suggesting that individuals with increased anxiety are more likely to be obese and smoke (Fluharty, 2017).

     The prevalence of depression among the studied students was significantly higher among those reported sleeping disorders. Students reported sleeping < 6 hours and > 8 hours a day, those spent for > 2 hours in bed before sleeping and those taking sleeping medication showed a significant high level of depression compared to other students where the prevalence was 47.1% and 48.2%, 52.2%, respectively. Sleep disturbances commonly are associated with many psychologic disorders including anxiety disorders, and depression, and sleep loss may exacerbate and contribute to relapse of these conditions (Schlarb et al., 2017).

     The study findings revealed varying level of depression among the studied students according to their study related factors. The prevalence was relatively low among students studying in a group all the time (28.5%), those reported that studying does not limit their social activity (34.1%), and among those studying less than 2 hours per day (39.1%). Unexpectedly, the depression level was high among students with high grade scores (44.8%) and 43.1% among those with very good and excellent grades, respectively. In contrast to this finding, Maurer, (2012) and
Sarokhani, (2013) reported a low prevalence rate of depression among students with moderate and high performance in examination. However, the finding of the present study could be attributed to the possibility that students with high academic grades are always in stress to keep their high performance and academic achievement and to engage into a specific speciality after their graduation.

CONCLUSION AND RECOMMENDATION

     The prevalence of depression was high among the studied medical students, particularly among females, living away from families and early study years students. Residence, social status and dietary habits play great role in the prevalence of depression among the studied sample. Also, the study and sleeping related factors appeared to influence the prevalence in the studied students. Addressing these results at faculty level may help to increase awareness of students and faculty administrators about this health problem. Also, the findings of study may encourage more researchers to take this important topic into their consideration studying it on large scale in well-designed longitudinal study with the aim to develop effective preventive and counseling services for the students. Future research will need to include students from other health related faculties such as faculty of pharmacy; dentistry and nursing to assess the extent of the problem in students affiliated to different health related faculties.

REFERENCES

1. Abdel Rahman AG, Al Hashim BN, Al Hiji NK and Al-Abbad Z. (2013): Stress among medical Saudi students at College of Medicine, King Faisal University J Prev Med Hyg., 54(4):195-199.
2. Abdulghani HM, AlKanhal AA, Mahmoud ES, Ponnamperuma GG and Alfaris EA. (2011): Stress and Its Effects on Medical Students: A Cross-sectional Study at a College of Medicine in Saudi Arabia. Journal of Health, Population, and Nutrition., (5):516-522.
3. Eisenberg D, Hunt J and Speer N. (2013): Mental health in American colleges and universities: variation across student. J Nerv Ment Dis., 201:60-67.
4. Fluharty M, Taylor A E, Grabski M, and Munafò MR. (2017): The Association of Cigarette Smoking With Depression and Anxiety: A Systematic Review. Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco, 19(1): 3-13.
5. Guilbeau JR. (2012): Health risks of energy drinks: what nurses and consumers need to know. Nurs Womens Health. 2012;16(5):423-428.
6. Ibrahim MB and Abdelreheem MH. (2015): Prevalence of anxiety and depression among medical pharmaceutical students in Alexandria University. Alexandria J Med., 51: 167-173.
7. Ibrahim N, Al-Kharboush D, El-Khatib L, Al-Aabib A and Asali D. (2013): Prevalence and Predictors of Anxiety and Depression among Female Medical Students in King Abdulaziz University, Jeddah, Saudi Arabia. Iran J Public Health, 42(7): 726-736.
8. Löwe B, Wahl I, Rose M, Spitzer C, Glaesmer H, Wingenfeld K, Schneider A and Brähler E. (2010): A 4-item measure of depression and anxiety: validation and standardization of the Patient Health Questionnaire-4 (PHQ-4) in the general population. J Affect Disord., 122(1-2):86-95.
9. Mancevska S, Bozinovska L, Tecce J, Pluncevik-Gligoroska J, Sivevska-Dahlin M, Joneborg N and Runeson B. (2015): Stress and depression among medical students: a cross-sectional study. Med Educ., 39:594-604.
10. Maurer DM. (2012): Screening for depression. Am Fam Physician, 85(2):139-144.
11. Myoung-Sun R and Sung KH. (2010): The Prevalence and Impact of Depression Among Medical Students: A Nationwide Cross-Sectional Study in South Korea. Academic Medicine., 85(8):1384-1390.
12. Sarokhani D, Delpisheh A, Veisani Y, Sarokhani MT, Manesh RE and Sayehmiri K. (2013): Prevalence of Depression among University Students: A Systematic Review and Meta-Analysis Study. Depression Research and Treatment, 373857:1-7.
13. Schlarb AA, Claßen M, Grünwald J, Vögele C. (2017): Sleep disturbances and mental strain in university students: results from an online survey in Luxembourg and Germany. Int J Ment Health Syst.,11:24.
14. Sepkowitz KA. (2013): Energy drinks and caffeine-related adverse effects. JAMA., 309(3):243-244.