Comparison of depression among medical and dental students of Qassim University 2019

INTRODUCTION

In the modern era, there is some importance gained at the higher education level for better opportunities. In this context, medical, dental and nursing education taken big momentum for good opportunities as well as society respectful professions. At the same time those students scored with maximum percentage and merit people only will enter into the professional medical education college or university. Though medical and dental students joined through merit list, initial phase in the university adjustment with other students, infrastructure, professional language skills and also orientation to medical and dental subjects and time bound task completion leads to tendency to develop stressful situation, that indirectly affect the students’ performance in the examinations. Sometimes it leads to suicidal tendencies also in some individuals.¹

An estimated 16.2 million adults in the United States had at least one major depressive episode. This number represented 6.7% of all U.S. adults.² The prevalence of major depressive episode was higher among adult females (8.5%) compared to males (4.8%). The prevalence of adults with a major depressive episode was highest among individuals aged 18-25 years (10.9%).³ Depression prevalence in primary care varies between 15.3-22%, with global prevalence up to 13% and between 17-46% in Saudi Arabia.⁴

There were different studies conducted in India and Pakistan among Medical and Dental university students and revealed that medical students are more susceptible to depression than general population. Prevalence of depression ranging from 63 to 75.5%.^5-8 A study conducted among private medical college students (n-336) Bareilly and depression stated as 49.1%. In his cross sectional survey anonymous questionnaire was used and tool used in his study was Beck inventory depression scale.⁹

Similarly study conducted by Alharbi et al in Saudi Arabia among 2562 students from 20 universities, published in December 2018 among medical students and prevalence mentioned in their study was 83.4%.¹⁰ In view of the high prevalence of depression and other above circumstances, present study was conducted in our province to see the demographic and risk factors associations with depression.

Objectives

To estimate the prevalence, compare the depression in medical and dental students of Qassim University and to find the risk factors association with depression.

METHODS

This chapter included study design, sample size calculation, method of data collection from the participant, statistical analysis and ethical considerations.

Study design and setting

This was a cross sectional study carried out at Qassim University medical and dental students from first year to final year students. All male and female students were included in the study.

Sampling method

Due to COVID-19 pandemic situation, in relation to selection of students from the class, initially contacted the all faculty in-charges and student class representatives to collect whatsApp and mobile numbers directory purpose. Personally contacted telephonically to the student representatives and sometimes contacted students through whatsApp communication, before sharing the questionnaire to the concerned student groups. Questionnaire was prepared as Google forms, then prepared a link, shared through e mails and whatsApp communication to all the student groups. Regular reminders kept for all student groups once in 3 days. Questionnaire circulated to 585 students and 174 people only responded in medical stream. Similarly among 290 dental students questionnaire was circulated and responded 61 students only. Universal sampling taken in the present study.

Sample size

Sample size was calculated by using WHO software for sample size determination. Prerequisites for the sample size calculation, at 95% confidence level, 5% precision and a reported prevalence of 83.4% of depression among medical students.¹⁰ Based on the above formulae, the calculated sample size was 213. Then identified all the batches from first year to final (5^th) year in medical and dental colleges Qassim university. Finally through Google forms collected 174 medical and 61 dental students in our study. As per the sample estimation, the sample size was 213. In view of data collection from Google forms, the total number of participants were increased to 235, another 10% excess sample taken to maintain the adequacy and good statistical test applications to draw some inferential conclusions.

Study period

This study was conducted from March 2019 to June 2020.

Target population

All Medical and dental students of Qassim university from the first year to 5th year.

Inclusion criteria

All the medical students and dental students from first year to 5^th year.

Exclusion criteria

Primary preparation year, freezing study and internship students exempted from the study.

Sampling technique

Whole sample taken in the study as universal sampling.

Data collection tools

Self-administered questionnaire and circulated through whatsApp and mail communication.

Questionnaire:

Questionnaire consists of socio-demographic variables and patient health questionnaire components. Questionnaire has gone through different stages to finalize the existing questionnaire. Validation of questionnaire done by Family medicine consultants, research experienced faculty and the concerned research supervisor at the Family Medicine Academy. PHQ-9 was quite commonly used tool at the community level as screening tool to diagnose the depression in developing and developed world. Another important area is that patient health questionnaire components and its grading classified as no depression (score 0-4), mild depression (score 5-9), moderate depression (score 10-19) and severe depression (score 20-27).

Statistical analysis:

Data cleaned and collected information will be entered and analysed by using “statistical package for social sciences” (SPSS) software Version 21.0 (Chicago). A descriptive analysis of the data will be done as means with standard deviations for quantitative variables and frequencies with proportions for qualitative variables. For qualitative analysis, the chi-square test will be used. Fisher’s exact test was considered if ≥25% of the cells had an expected frequency of less than 5. The level of significance will be taken as p≤0.05. Multiple binary logistic regression analysis was used for prediction of risk factors after adjustment of all other factors.

Pilot study

Pilot study conducted on 20 medical residents and 10 dental students in the month of December 2019 and collected altogether 30 sample. This sample was not included in the main study sample. After pilot study there was no modification of questionnaire done.

Ethical considerations

Institutional ethical committee approval will be taken from Qassim Regional Bio-Ethics Committee. Subsequently obtained permission approval from the Deans of Qassim medical and dental college. Before collection of the data, informed consent form attached to the each Google questionnaire and oral consent taken from all respondents before circulation. Confidentiality of all participants will be ensured at all stages of study including in the personal identity to the results presentation.

RESULTS

In the present study, total of 235 students were participated in the study. Majority of the students were not responded. Average response rate among both medical and dental students was 26.8% (235/875). Of which, 174 medical students and 61 dental students were participated. Among the medical students, about 108 (62.1%) were males and 66 (37.9%) were females. Similarly among the dental students, about 24 (39.3%) were males and 37 (60.7%) were females. Out of 174 medical students, about 72.5 % were in the age group of 21-24 years. Nearly three fourth of the participants were having their family income >10,000 SR per month. Maximum students participated from 4^th year level. Among the dental students, about 60.7% were females. Almost 84% were in the age group of 21-24 years. Maximum of 29.5% of students participated from 5^th year. About two third of dental students families, family income was >10,000 SR per month. In the study population, about 82.75% (144/174) medical students were having depression and 86.9% (53/61) dental students were having depression in study population. Of which severe depression among dental students was 11.5% and medical students was about 8.6%.

About only one third of medical students academic performance was good and 10.3% were current smokers. In relation to recent deaths in the family for the last 1 year, about 17.2% were revealed that recent deaths in their family and also same proportion revealed that financial difficulties in their families. About 30% of the medical students revealed that presence of psychiatric illness in their family (Table 1). Figure 1 stated that prevalence of depression among medical students was 82.90%.

Present study stated that 54.1% of the dental students were showing good academic performance. About 9.8% were active smokers and 23% of the dental students experienced recent deaths in their families for the past 1 year. About 37,7% were having psychiatric illness in their families (Table 2). Figure 2 shown that prevalence of depression among dental students was 86.90%.

Current study revealed that among the medical students, about 54% of the families having diabetes as common chronic disease, 44.3% were hypertension and 27.6% were dyslipidaemia condition. About 16.7% of the medical student families were having major depressive disorder and 14.9% were having generalized anxiety disorder. Similarly in case of dental students, about 52.5% of the families were having as common chronic disease as diabetes and 47.5% were having hypertension problem. About 16.4% were having major depressive disorder in their families and 24.6% were having generalized anxiety disorder (Table 3). In the present study revealed that about depression among female medical students was 87.9% and males was 79.6%. There was statistically significant association was observed with low socio-economic status (family income 3000-10000 SR/month) with depression status (p<0.05, Table 4).

In the current study stated that about depression among male dental students was 87.5% and females was 86.5%. There was statistically significant association was observed with low socio-economic status with depression status (p<0.05, Table 5). Present study stated that in the study population, after adjustment of all other factors, chronic disease in the family was significantly associated with depression in the medical students (Odd's ratio 0.391, p<0.05, Table 6). Current study revealed that in the study population, after adjustment of all other factors, deaths in family for the last one year was significantly associated with depression in the dental students (odd's ratio 0.210, p<0.05, Table 7).

DISCUSSION

This present study was conducted among the Medical and Dental students of all years (from first year to fifth year) studying at Qassim university during the period from March 2020 to June 2020 and selected the students as per the study guidelines to see the main objective of comparison of depression among medical and dental students.

The mean age of the medical students and standard deviation were noticed in the present study as 22.19±1.829. Among the dental students, the mean age and standard deviation was about 22.38±1.507. Similar result of age group range and same mean age was observed in the study conducted in Pakistan among public sector medical university students.¹⁵ Incidentally 25% of the both medical and dental students less than 21 years, 50 percentage of the students were more than 22 years and lastly 75% of the both medical and dental students were less than 23 years of age.

In comparison to mean age, other study conducted in Saudi Arabia among 20 universities by 27 data collectors in the year 2018 and same tool of Patient health questionnaire-9 was used and revealed the mean age and standard deviation shown as 22.05±1.98.¹⁰

Depression among medical students was 82.80% and about dental students was about 86.90%. Similar observation was found by a study done by Alharbi et al in Saudi Arabia among medical students, the prevalence reported in his study was 83.6%.¹⁰ In spite of high depression prevalence in the present study, severe depression prevalence among the both medical and dental students was less 11.5% and 8.6% respectively.

In Saudi Arabia majority studies conducted on depression and prevalence was recorded more than 50%.^10,11 Other studies conducted in Pakistan revealed that a study conducted on students of MBBS in Sargodha Medical College in March 2017, showed that depression in medical students was very high, 75.5% students reached depression criteria and another study conducted at Shalamar Medical and Dental College showed the prevalence of depression to be 63%.^7,8 In Malaysia by Fuad MD et al stated that prevalence of depression was 60.2%.¹⁴

There were some studies done on different parts of world, where prevalence of depression was reported less in medical and dental students and also in general population. Prevalence of depression among dental students in Kerala noted that about depression was estimated as 26.9% (95% confidence interval: 22.4-31.8).¹³ The prevalence of depression among Ethiopian population reported as 24.5%, in Malawi east Africa the depression was 30.3%.^16,17

In our present study, there was no significant association was observed between gender and depression status in both medical and dental students. But in some studies conducted at different places revealed that there was significant association and also high prevalence of depression was observed among the female gender. Different prevalence of depression reported in the following studies as among females was 28.4% and that of males was 20.8%. The high prevalence of depression among females was evident in similar studies in different parts of the world like Ethiopia West Bengal and the United States of America.^16,18,19

This high prevalence could be due to type of tool was used. In case of patient health questionnaire consideration of score as normal was 0-4 only. Score above 5 onwards mild depression category will start. Second thing was that self-administered questionnaire some of the variables, participant may misunderstood and also sometimes leads to wrong interpretation. If the principal investigator is available during data collection, that will solve some misunderstanding variables issues. During COVID-19 era, unforeseen situation and social distancing, questionnaire circulated through Google forms.

PHQ-9 was used, which contained nine questions based on DSM-IV. The questions are arranged as Likert scale and graded from 0 to 3 (not at all, several days, more than half the days, and nearly every day). The Likert items were computed as a total score. The score ranges from 0-27, Out of total score categorized in a diagnostic algorithm, where a score of 0-4 as normal people, score of 5–9 is considered mild, 10–19 moderate depression, and ≥20 is severe depression.²⁰

In relation to predictors of depression status, Al-Saleh SA, Al-Madi EM et al conducted a study in Saudi Arabia revealed that marital status and financial responsibilities were not significant predictors of depression, anxiety, or stress in their research. Other studies have also found that students marital status is not a significant predictor. Generally married students may be more prone to stress due to their increased responsibilities in addition to academic activities. No tuition fees for education at Kingdom of Saudi Arabia University, in addition to the monthly stipend may reduce the effects of financial factors on depression.^21,22 Because of stipend to the students, all the students family income boosted to more than 3000 SR per month in all the student families. One of the limitation of the study was as the questionnaire was self-administered questionnaire, some of the questions may misunderstood and response rate was also low because questionnaire forms circulated through Google forms.

CONCLUSION

Based on the study results, high prevalence of depression was noticed in both the medical and dental students. Multiple logistic regression analysis was done with different risk factors and depression, chronic disease in the family was significantly associated with depression in the medical students. Similarly among the dental students, binary logistic regression analysis was applied with different risk factors, deaths in family for the last one year was significantly associated with depression in the dental students (p<0.05). Socioeconomic status was significantly associated with depression among medical and dental students of Qassim University. Need to identify the problem early and suggesting some life style modifications and supportive programs adoption will reduce the depression burden certain extent. Student motivation is more important than other enforcement of rules in the institute. Need similar sample studies in our province are required to substantiate the present study findings.

ACKNOWLEDGEMENTS

Special and respectful gratitude towards Deans of Medical and Dental Colleges and all the students who were participated in our study. I am very much thankful to Mohamaad Saleh AL Samaani, Intern of College of Medicine, Qassim University for his meticulous help in data collection in relation to identification of students and their groups and thorough follow to complete the questionnaire.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Costa EF, Rocha MM, Santos, AT, Melo EV, Martins LA, Andrade TM. Common mental disorders and associated factors among final year health care students. Rev Assoc Med Bras. 2014;60(6):525-30.
2. 2. American Psychiatric Association. What Is Depression. Available from: https://www.psychiatry.org/patients-families/depression/what-is-depression. Accessed on 15 December 2018.
3. 3. National Institute of Mental Health. Prevalence of major depressive episode among adults. Available from: https://www.nimh.nih.gov/health/statistics/major-depression.shtml. Accessed on 15 December 2018.
4. 4. Al-Qadhi W, ur Rahman S, Ferwana MS, Abdulmajeed IA. Adult depression screening in Saudi primary care: prevalence, instrument and cost. BMc Psychiatr. 2014;14(1):190.
5. 5. Khan TA, Arif H, Sabahat S, Khan G, Khan A. Depression among medical students of a public sector medical university in Pakistan. Ann Clin Obstet Gynecol. 2019;1(1):1005.
6. 6. Schwenk TL, Davis L, Wimsatt LA. Depression, stigma, and suicidal ideation in medical students. JAMA. 2010;304(11):1181-90.
7. 7. Uttra AM, Uttra MGM, Rauf A, Uttra MM, Hassan UH, Batool A. Prevalence of depression; a cross-sectional study among MBBS students of Sargodha medical college, Sargodha Pakistan. Prof Med J. 2017;24(3):482-9.
8. 8. Naz N, Iqbal S, Mahmood A. Stress, anxiety and depression among the dental students of university college of medicine and dentistry Lahore; Pakistan. Pak J Med Health Sci. 2017;11(4):1277-81.
9. 9. Singh A, Lal A, Singh S. Prevalence of depression among medical students of a private medical college in India. Online J Health Allied Sci. 2011;9(4).
10. 10. Alharbi H, Almalki A, Alabdan F, Haddad B. Depression among medical students in Saudi medical colleges: a cross-sectional study. Adv Med Educ Pract. 2018;9:887.
11. 11. Aboalshamat K, Hou XY, Strodl E. Psychological well-being status among medical and dental students in Makkah, Saudi Arabia: A cross-sectional study. Med Teach. 2015;37(sup1):S75-81.
12. 12. Basudan S, Binanzan N, Alhassan A. Depression, anxiety and stress in dental students. Int J Med Educ. 2017;8:179.
13. 13. Raghunathan D, Ramakrishnan D, Valsan KI, Ambika S. Prevalence of depression among students of a dental tertiary care center in Kerala. Indian J Community Med. 2019;44(Suppl 1):S14.
14. 14. Fuad MD, Al-Zurfi BM, AbdulQader MA, Bakar MF, Elnajeh M, Abdullah MR. Prevalence and risk factors of stress, anxiety and depression among medical students of a private medical University in Malaysia in 2015. Educ Med J. 2015;7.
15. 15. Khan TA, Arif H, Sabahat S, Khan G, Khan A. Depression among medical students of a public sector medical university in Pakistan. Ann Clin Obstet Gynecol. 2019;1(1):1005.
16. 16. Tilahune AB, Bekele G, Mekonnen N, Tamiru E. Prevalence of unrecognized depression and associated factors among patients attending medical outpatient department in Adare hospital, Hawassa, Ethiopia. Neuropsychiatr Dis Treat. 2016;12:2723-9.
17. 17. Udedi M. The prevalence of depression among patients and its detection by primary health care workers at Matawale Health Centre (Zomba). Malawi Med J. 2014;26(2):34-7.
18. 18. Chaudhuri SB, Mandal PK, Chakrabarty M, Bandyopadhyay G, Bhattacherjee S. A study on the prevalence of depression and its risk factors among adult population of Siliguri subdivision of Darjeeling district, West Bengal. J Family Med Prim Care. 2017;6:351-5.
19. 19. Laurence B, Williams C, Eiland D. Depressive symptoms, stress, and social support among dental students at a historically black college and university. J Am Coll Health. 2009;58:56-63.
20. 20. Pinto-Meza A, Serrano-Blanco A, Peñarrubia MT, Blanco E, Haro JM. Assessing depression in primary care with the PHQ-9: Can it be carried out over the telephone? J Gen Intern Med. 2005;20:738-42.
21. 21. Al-Saleh SA, Al-Madi EM, Al-Angari NS, Al-Shehri HA, Shukri MM. Survey of perceived stress-inducing problems among dental students, Saudi Arabia. Saudi Dent J. 2010;22(2):83-8.
22. 22. Muirhead V, Locker D. Canadian dental students’ perceptions of stress. J Can Dent Assoc. 2007;73(4):323.