الفهرس 
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Abstract
Depression is a common mood disorder that causes a persistent feeling of sadness, depressed mood, decreased energy, feelings of guilt or low self-worth, disturbed sleep or appetite, poor concentration and loss of interest or pleasure.Depression leads to a variety of emotional and physical problems that might affect day-to-day activities that make a person feel as if life isn’t worth living. Moreover, depression often comes with symptoms of anxiety.
In 2008, the World Health Organization reported that depression was ranked the third most prevalent moderate and severe disabling condition globally. University students are a special group of people at a critical transition period in which they are going from adolescence to adulthood, which can be one of the most stressful times in a person’s life.Several studies have reported high rates of depression and psychological morbidity among medical students as compared to the general population.
Objectives of the study:
1. To estimate the prevalence of depression among medical students in Alexandria during 4th, 5th and 6th academic years.
2. To identify the possible determinants of depression among medical students in Alexandria.
Subjects and methods:
A cross-sectional design was used. The study was conducted at the Faculty of Medicine, Alexandria University. The target population was medical students attending 4th, 5th, and 6th academic years. Using EpiInfo 7, the sample size was calculated based on a prevalence of depression among medical students of 57.9%, and a confidence limit of 5%. The minimum required sample size at 95% confidence level was 374, and was rounded to 390. An equal number of students was selected from 4th, 5th and 6th academic years (130 each), with equal numbers of males and females (65 each). A systematic random sampling technique was used to select the students.
The data collection tools included:
I. A predesigned, self-administered, structured questionnaireto collect the following data from medical students:
• Socio-demographic data.
• Personal habits.
• Social life.
• History of chronic diseases.
• History and Family history of mental illness.
• Academic environment and perspective towards exams.
II. The Arabic Version of the Beck Depression Inventory-2nd edition (BDI-II)
The BDI-II is a screening tool that assesses the intensity of depressive symptoms. Scores range from 0 to 63, and intensity categories vary from minimal (0–9), mild (10–16), moderate (17–29), and severe (30–63). The cutoff point of diagnosing depression is a score of 10 or more. BDI-II is a structured self-report instrument that is composed of 21 multiple choice categories of symptoms and attitudes, describing behavioral manifestations of depression. The respondent must recall, based on the previous two weeks, the relevance of each statement relating to: sadness, pessimism, sense of failure, loss of pleasure, guilt, expectation of punishment, dislike of self, self-accusation, suicidal ideation, episodes of crying, irritability, social withdrawal, indecisiveness, worthlessness, loss of energy, insomnia, irritability, loss of appetite, preoccupation, fatigue, and loss of interest in sex.
Results:
Section I: Description of the study sample:
- The students’ age ranged from 20 to 27 years, with mean age 22.9 ± 1.7. Regarding students’ sex, 49.7%, and 50.3% of the students were males and females, respectively. Single students accounted for 86.7% of the study sample, 58% were originally from Alexandria, 53.3% of the students lived with their families, and 55.6% of the students reported that the family income was sufficient and allowed saving. Most (81.5%) students had a crowding index of 1- < 3. About 57%, and 60% of the fathers and mothers, respectively, got university education, 50.3% of the students’ fathers had professional jobs, and 57.2% of their mothers were working. As regards to the method of transportation, 82.3% of the students reported using public transportation.
- About 67% of the students didn’t play any sports, and about 77% of the students had other hobbies including reading, playing electronic games, cooking, and travelling. Concerning tobacco smoking, 9.2% were smokers, and 11% were shisha smokers. Substance abuse was reported by 6.1% of the students, and Cannabis was the most commonly used substance (75%).
- Regarding students’ social life, 90.8% of the students had close friends. When under stress, 69% of the students had someone whom they can talk to, 59.7% were exposed to stressful life events during the last six months, and 85.4% were satisfied with their socioeconomic level.
- Concerning the students’ medical history, 23.1% of the students suffered from chronic diseases, 47.2% reported having history of mental illness, and 25.4% reported the presence of history of mental illness in their families.
- Regarding the academic environment conditions, 20.5% of students reported that they didn’t join the Faculty of Medicine according to their own will. Their grades during the previous academic year varied between very good (39.5%), good (26.7%), excellent (25.4%), fair (5.6%), and 2.8% failed, and 32.1% were satisfied with the grades they got.
- Regarding the college expenses, the majority of the students (89.5%) didn’t face any difficulties in paying them. Students who regularly attended lectures represented 27.4% of the whole study population. Regarding the availability of professors during office hours, 33.9% reported that professors were not available during office hours.
- Students who stated that the environment where they live does not help them study (36.2%) mentioned different reasons; among them were noise, moving away from family, and overcrowding. Regarding the scope of the lectures, students approving that lectures sufficiently covered the syllabus were only 10.8%, and 11% totally dependent on private lessons.
- The highest percent of students (60.0%) strongly disagreed that studying medicine allows them to keep the balance between their social and academic life, also 6.4% strongly disagreed that professors are cooperative and willing to offer help concerning academic aspects. Regarding the exams’ transparency, only 4.1% strongly agreed that the oral and clinical exams were being held with transparency.
Section II: Prevalence and determinants of depression among medical students:
- According to BDI-II score, minimal and mild depression counted for 32.6%, and 22.3% of the students, respectively, and moderate and severe depression represented 27.9%, and 17.2% of the total sample, respectively.
- The prevalence of moderate and severe depression were higher among:
• Female students (51%) versus 39.2% of the male students.
• Lower crowding index.
• Students not practicing any sports (49.4%).
• Students who did not have a hobby (51.1%).
• Students who reported substance abuse (54.2%) compared to 44.5% of those who did not.
• Students who did not have any close friends (63.9%), compared to 43.2% of those who had close friends. The association was statistically significant (p=0.018).
• More than half of the students who did not have anyone to talk to when under stress, in comparison to 41.6% of the students who had someone to talk to. The association was statistically significant (p=0.039).
• Students who reported experiencing a stressful life event(s) (54.9%), compared to 30.6% of the students who did not experience any stressful events during the previous 6 months. The association was statistically significant (p=0.000).
• About two-thirds (61.4%) of the students who were not satisfied with their socioeconomic level, versus 42.3% of those who were satisfied. The association was statistically significant (p=0.008).
• Presence of mental illness(es) (64.1%), versus students who reported not having any mental illness(es) (28.2%). The association was statistically significant (p=0.000).
• About 60% of the students who had positive family history of mental illness(es), versus 40.5% of the students who did not have family history of mental illness(es). The association was statistically significant (p=0.002).
• Students who disagreed and strongly disagreed that the gap between exams was sufficient. The association was statistically significant (p=0.005).
• Reporting that the surrounding environment did not help them study (58.9%). The association was statistically significant (p=0.000).
- Moderate and severe depression decreased by the increase of:
• Students’ age.
• Academic year.
• Father’s level of education.
- Moderate and severe depression increased by the decrease of:
• Family income.
• Students’ satisfaction with their results. The association was statistically significant (p=0.007).
• Students’ agreement that studying medicine gives them opportunity to balance between their social and academic life (53.8% among those who strongly disagreed). The association was statistically significant (p=0.000).
- It was also found that the majority (65.2%) of students who joined the faculty according to their own will had very good and excellent grades during the previous academic year. The association was statistically significant (p=0.000).
- Regarding the logistic regression analysis with the level of depression as the dependent variable, the social life and medical history in addition to sex were the independent variables used to build the first model. Four variables were significantly affecting the level of depression among medical students. These factors were not having someone to talk to when under stress,experiencing stressful life events during the previous 6 months, dissatisfaction with the socioeconomic level, and the presence of mental illness(es). The model correctly classified 69.7% of cases.
- The perspectives towards lectures and exams in addition to sex were the independent variables used to build the second model. Four variables were significantly affecting the level of depression among medical students. These variables were being a female (OR=1.7, CI 1.04-2.71), strongly disagreeing that the surrounding environment was suitable for studying (OR=2.1, CI 1.28-3.27), not specifying a grade to achieve this year (OR=1.7, CI 1.05-2.82), and finally, extreme dissatisfaction with the student’s result for the previous academic year (OR=3.45, CI 1.48-8.09). The model correctly classified 68.5% of the cases.
Conclusion:
Moderate and severe depression accounted for 27.9%, and 17.2%, respectively. They were significantly associated with the presence of close friends, satisfaction with socioeconomic level, experiencing stressful life events during the previous six months, the presence of mental illness, and family history of mental illness, moreover, the student’s satisfaction with their result during the previous academic year, and specifying a grade to achieve this year, the regularity of attending lectures, and if the surrounding environment was suitable for studying.
Female gender, the presence of mental illness, not having someone to talk to when under stress, experiencing stressful life event(s) during the previous 6 months, and not being satisfied with the socioeconomic level, reporting that the surrounding environment is not suitable for studying, not specifying a grade to achieve, and extreme dissatisfaction with the student’s result are independent predictors for moderate and severe depression.
Recommendations:
Efforts should be made to establish stress management courses early from the start of the medical education. Counseling and preventive mental health services for both students at risk of developing depression, and the whole student population as well. Students who are already diagnosed with depression must be referred to receive care being counselling, psychotherapy, medical treatment, or a combination of them. Regular health education sessions should be held to increase the awareness about stress, burnout, anxiety and depression. Practicing a sport or having a hobby should be encouraged, and having someone to talk to and ventilate is essential to prevent depression.