The present study determined the prevalence and predicted factors of depression among medical students at the UBCOM, Bisha province in the southern region of Saudi Arabia. The overall prevalence of depression among students was 26.8%. This finding was higher than that reported among medical students at King Faisal University in the eastern region of Saudi Arabia (16.2%). However, our result was lower than that reported among medical students in Albaha University in Albaha neighboring city (53.8%), in Umm Al-Qura University, Makkah Al-Mukaramah (34.5%), and in King Saud University, Riyadh capital (48.2%). In neighboring countries, the prevalence of depression among medical students found to be 17.2% in Oman , and 40 % in Bahrain. Moreover, recent studies from other countries revealed variable prevalence rates of depression ranging between 71% to 13.6% [4,22–25]. Such discrepancy in the level of depression could be attributed to the differences in socio-cultural and demographic structures of medical students or due to the variation of academic environments between medical schools. Other possibilities might be to the differences in sample size selected, types of tools for depression assessment and the cut off values used to estimate the rate of depression.
Comparing the level of depression by the academic year, the second-year students scored the highest depression rate. This result is consistent with previous studies using different assessment tools for depression. For instance, high rates of depression have been determined by the PHQ–9 scale among the second-year medical students in Korea , and Malaysia. These observations could be explained by that medical students could face a more complex curriculum in the second year. In fact, the first cycle of the medical curriculum in UBCOM starts from year two, where the students should understand the extensive basic knowledge of the human body and function in health and disease in this phase. Increasing the level of depression among students during the early stages of medical schools has been reported in several studies. Vankar et al. determined that the prevalence of self-identified depression was significantly higher in the first year and second years as compared to the third and fourth years. In a longitudinal study, Roh et al. have suggested that depression rates increase during the first year and then reach the peak level during the second year, followed by a gradual decline during the later years of medical school. A recent study in Saudi Arabia conducted among medical science students found the level of depression starts to escalate from the pre-professional year, reach the peak at the third professional year and then decreased in the final year of graduation.
Interestingly, our sixth-year students recorded the second-highest rate of depression. This might be due to the increasing demand for clinical training, along with new concerns and responsibilities of students during such academic levels. A recent study highlighted several stressful situations like using psychometric skills, applying clinical knowledge in real-life situations, trauma exposure, understanding the role and regulating of clinical settings during their clerkship. Lin et al. argued that medical students, as novices in medical practice, experience greater physical demands resulting from their lack of efficiency or familiarity with the workload, leading to frustration in learning and reducing their compassion satisfaction. Therefore, understanding of clinical learning process along with essential supervision by clinicians in various disciplines might lead to a stress-free learning environment for our students in patient care and hospital setting.
In the present study, we identified a combination of predicted factors associated with depression. In univariate analysis, students who perceived insufficient family income were about three times tend to get depressive symptoms than other students. This association has been reported by many authors[19,28]. However, our result failed to determine a significant association between depression and family income at the multivariate level when adjusting other confounding factors. A previous study in Saudi Arabia suggested an insignificant association between the financial income and likelihood of depression due to the subjectivity of the income estimation.
The present study indicated that the loss of family members and having psychological illnesses were possible risk factors for depression. However, at the multivariate level, the loss of a family member remained a significant indicator of depression. Likewise, studies in Saudi Arabia linked the presence of depressive symptoms with physiological illness[2,13], and the loss of a family member. Furthermore, inconsistent with a previous study in Saudi Arabia, we did not find significant associations between depression and parents’ educational levels.
In the present study, medical students who had difficulties in personal relationships were about two and a half times more tendencies to develop depression. This might be attributed to the heavy academic requirements of studying medicine, which leave no time for building good personal relationships with friends or society. The other possible reason is that many students at UBCOM who are leaving their base home could fail to adapt to the new society and environments. Previous studies related increasing the rate of mental disorders to the feeling of isolation from family and community[15,25]. The high rate of depression observed among our students those having difficulties in personal relationships highlighted the importance of social support from peers, faculty members, activating of students’ academic counseling. However, focus group discussions with our students might be an essential approach to figure out their essential needs.
Several studies have evaluated the contribution of depression-related factors to the academic status of the medical institution[2,19]. In our findings, students perceived a lack of college facilities were about three times depressed than other students. Likewise, a study conducted at King Saud University in Riyadh capital found that medical students with negative perceptions about the educational environment were having a high rate of depressive symptoms. Additionally, since UBCOM is a newly established medical school, it still has limitations in infrastructure and educational facilities. Therefore, university administration could play a crucial role in supporting the learning environment overall the medical school.
Evidence indicated that students at medical school could impose significant psychological stress due to substantial academic requirements[2,22]. In the present study, the regret of studying medicine is the persistent and strong factor for causing depression. However, having a regret feeling of studying medicine found to be a correlate of depression in many studies[4,30]. This can be explained by that many students might found curriculum difficulties and demanding nature of studying medical school than they expected. However, our study found a significant association between depression and heavy academic load. Another possible factor could be a lack of interest and motivation of students after joining the medical school. Research showed that many students select a medicine career because of family pressure rather than their self-interest. Therefore, understanding the factors influencing students to choose medicine as a career are need to be investigated. Furthermore, implementing appropriate quality assurance procedures along with students’ perception are recommended to evaluate medical curriculum contents, teaching and learning strategies.
Regarding the academic performance, the proportion of depression was significantly increased among students who perceived their academic grade was lower than expected. Similar findings have been observed in Korea, and India. Yoon et al. found that academic achievement was significantly related to the mean PHQ–9 score, and the prevalence of depression was significantly higher in poor-perceived academic achievers than in excellent or fair achievers. In contrary, another study assumed that higher academic achievers might be under massive stress due to the competitive nature of the medical school. The present study also found a strong association between academic failure and depression, confirming previous findings. Research evidence indicated that depressive symptoms among medical and non-medical students were linked to frequent courses failure and lower curricular average grade. Noticeably, our medical students who failed at least in one academic year or a course were about three times depressed than those who are not failed during their study. Such a situation urge for adopting a mentorship program combined with academic counseling and psychiatric services to guide students toward academic excellence.
The study provides several limitations that need to be considered. Firstly, this was a cross-sectional design that used a self-assessment measure without any confirmation from clinical physicians. Secondly, depressive symptoms were identified based on a PHQ–9≥10 score; therefore, the association between risk factors and the severity of depression was not identified more clearly. Thirdly, the study did not include students who dropped or absent during the survey, which might affect the rate of depression among our medical students. Finally, the study included only male students; in fact, the medical program for the females at the UBCOM had not yet started.