Incidence of Depression, Anxiety and Stress among Final- Year Medical Students versus Internship Graduates of Faculty of Medicine, Sana'a University 2023

doi:10.21203/rs.3.rs-4814208/v1

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Incidence of Depression, Anxiety and Stress among Final- Year Medical Students versus Internship Graduates of Faculty of Medicine, Sana'a University 2023

https://doi.org/10.21203/rs.3.rs-4814208/v1

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Background: Depression, anxiety, and stress among medical students are significant health issues due to their impact in the challenging journey in medicine.

Objective: To assess the relief in depression, anxiety, and stress attributed to graduation of final year medical students of Faculty of Medicine and Health science, Sana'a University, Yemen in 2023.

Methodology: Cohort design was employed. Volunteers were 408 with a response rate of 99.8%. They were contacted electronically through faculty registries. The Final year respondents were 212 and the interns were 197. The data were collected by using questionnaire that including socio-demographic characteristics and a validated self-administered questionnaire DASS-21 to assess depression, anxiety and stress. The collected data were analyzed by using (SPSS) version 26. Ethical Clearence Cetrificate was taken from The Faculty of Medicine, Sana'a University.

Results: Final year medical students had incidence rates of 74.1% depression, 66 % anxiety and 62.7 % stress. While, internship graduates 63.96% were depressed, 56.9% anxious and 45% were stressed. The relief were significant from depression (p=0.032) and stress (p<0.0001), whereas not significant P=0.067 for anxiety.

Conclusion: The rates of depression, anxiety and stress are high among both cohorts. The relief attributed to graduation was significant for depression and stress.

A mental disorder is characterized by a clinically significant change in an individual’s cognition, emotional regulation, or behavior. It is generally associated with distress or impairment in important areas of functioning. In the year 2019, 301 million people were living with an anxiety disorder, and 280 million people were living with depression. According to World Health Organization (WHO), depression is characterized by "a low mood or loss of pleasure or interest in activities for long periods of time". Depressive episodes last most of the day, nearly every day, for at least two weeks. Anxiety is experience of fear and worry that both intense and excessive. These feelings are typically accompanied by physical tension and other behavioral and cognitive symptoms. Stress is a state of worry or mental tension caused by a difficult situation. Stress is a natural human response that prompts us to address challenges and threats in our lives [1].

Medical students have been found to suffer from depression and anxiety at higher rates than the general population and their fellow students [2, 3]. A systematic review estimated that the average prevalence of depressive disorders in university students was 30.6%, significantly higher than reported in the general population [4].

The incidence of mental dysregulation among medical students is often attributed to competitive and stressful environments as well as other academic and professional demands, which often result in emotional exhaustion and psychological distress [5]. Several studies suggest that the transition time from premedical to medical, preclinical to clinical training and from clinical training to approaching qualification is particularly stressful for medical students [6, 7, 8].

The prevalence of depression, anxiety and stress among medical students varies depending on the country, the year of study, the assessment tool, and other factors. As an example of depression, a meta-analysis in different countries reported a rate of 28%[9]. In Fayoum University Egypt, a rate of 60.2% was reported [5]. In Bahrain (40%) [10], Ethiopia (51.30%) [11], Ain Shams University Egypt (64.2%) [12], Saudi Arabia (28–70.6%)[13].

As for anxiety, a meta-analysis about anxiety reported a rate of 33%[14], in undergraduate medical students of Fayoum University was 64.3% [5], Bahrain 51% [10], Ethiopia 30.10% [11], Ain Shams University Egypt 77.1% [12], Saudi Arabia 52.7–67% [13]. Finally, the prevalence of stress within undergraduate medical students in Fayoum university was 62.4%[5], Ethiopia (52.4%) [11], Ain Shams University Egypt 70.4% [12], in the systematic review in Saudi Arabia the rate was ranged between 30.5–90.7%[13], while in the developed countries like United States 49%[15].

The journey of Yemeni medical students is a rigorous one, filled with countless hours of study, clinical rotations, and high-stakes examinations. Yemeni students face challenges related to the difficult, unstable academic system due to the current crises of the civil war. As students transition into their final year and internship, the pressure intensifies, often leading to heightened levels of anxiety, depression, and stress. The objective of this study was to assess the relief in depression, anxiety, and stress attributed to graduation of final year medical students of Faculty of Medicine and Health science, Sana'a University, Yemen in 2023.

A cohort study is conducted to estimate the incidence of depression, anxiety, and stress among final year medical students versus internship graduates in Faculty of Medicine and Health Science, Sana'a University, Yemen 2023

Study Setting:

This study was conducted in Faculty of Medicine Sana’a University which is the first medical faculty in Yemen. It was established in 1982. Sana’a university considered as the biggest medical university in Yemen and enrolled a big number of students form different parts of the country. The academic and administrative staff in Sana’a university have been known by their qualification and good reputation. The journey of studying medicine lasts six years in addition to an obligatory year in internship to socialize graduates to their profession.

Sample Size and sampling technique:

The study population for both 6th year and interns were 830. The sample size was calculated by an online statistical calculator (statulator), assuming 20% differences between the two cohorts. The assumption was based on the global meta-analysis of anxiety which was 33%[14]. The required sample size was 193 for each group (total sample size 386 for both groups). A 10% increase in the sample size to overcome the loss or the nonresponse to become 409. All volunteers (n = 409) were contacted electronically through faculty registries. Only one participant declined to participate and the achieved response rate was 99.8%. The Final year respondents were 212 and the interns were 197. Then carried out through sending the questionnaire to all selected students in Telegram from both batches. Volunteers who reported using antipsychotic drugs, antidepressant drugs and the students refused to participates were excluded from the study.

A validated questionnaire DASS-21 was used. The DASS-21 is a short form of the DASS-42 [16], a self-report scale designed to measure the negative emotional states of depression, anxiety and stress. The DASS-21 consists of three subscales, each containing 7 items, that assess dysphoria, hopelessness, devaluation of life, self-deprecation, lack of interest/involvement, anhedonia, inertia, autonomic arousal, skeletal muscle effects, situational anxiety, subjective experience of anxious affect, chronic non-specific arousal, difficulty relaxing, nervousness, irritability, impatience and over-reactivity [17].

Individuals read each statement and circle a number 0, 1, 2 or 3 that indicates how much the statement applied to him/her over the past week. The rating scale is as follows :(0) Did not apply to me at all, (1) Applied to me to some degree, or some of the time, (2) Applied to me to a considerable degree, or a good part of time, (3) Applied to me very much, or most of the time, each scale of the DASS-21 is calculated by summing the scores of the items that belong to that scale and multiplying them by 2. The scores range from 0 to 42 for each scale [17].

Table (1): Recommended Cut-Off Scores for Conventional Severity Labels for DASS-21

	Depression	Anxiety	Stress
Normal	0–9	0–7	0–14
Mild	10–13	8–9	15–18
Moderate	14–20	10–14	19–25
Sever	21–27	15–19	26–33
Extremely Sever	28+	20+	34+

DASS-21 has been shown to possess adequate construct validity. The utility of the measure is enhanced by the provision of normative data based on a large sample [18].The Arabic version of the DASS-21 is a translation of the original English version, following a forward-backward procedure. It was psychometrically evaluated in an Egyptian sample of substance use disorder inpatients at a government psychiatric hospital. The results showed that the Arabic DASS-21 had good internal consistency, factor structure, and convergent validity [19].

3.8. Pilot study:

The online survey was pretested by administering it to 10 medical students who did not participate in the study to check the clarity and understanding of the questions and to ensure that the content and length were appropriate. Also, to estimate the time it will take to complete the questionnaire

Data was entered and analyzed by using Statistical Package for Social Sciences Version 26 (SPSS) software for appropriate statistical analysis. Descriptive statistics (i.e., frequencies, percentages, mean, standard deviation “SD”) were used to describe the demographic characteristics, depression, anxiety, and stress. Chi-square to assess if any association among variables of different questions had any statistical significance or not. A P value of 0.05 or less was taken as statistically significant.

An informed consent in the online survey was taken from all participants. The questionnaires were anonymous. Ethical clearance was obtained from the Committee of Research Ethics of the Faculty of Medicine and Health Sciences of Sana'a University which follow the Helsinki Declaration.

Socio-demographic characteristics

The data in Table (2) shows that the median age of final-year medical students was 25 years while the median age of internship graduates was 27years. Male participants were 114 (53.8%) from final-year and 100 (51%) from internship graduates, while females were 98 (46.2%) from final-year and 96 (49%) from internship graduates. Most of the participants lived with their family and represented 152 (71.7%) from final-year and 145 (73.6%) from internship graduates. Majority of the participants were unmarried 179 (84.4%) from final-year and 141 (71.6%) from internship graduates. The majority of the participants had good financial condition, as perceived by themselves,125 (59%) from final-year and 116 (58.9%) from internship graduates, while those who had very good financial condition were 57 (26.9%) from final-year and 43 (21.8%) from internship graduates. Also those who had limited financial condition were 30 (14.2%) from final-year and 38 (19.3%) from internship graduates. Most of the participants didn't work beside study and represented 199 (93.9%) from final-year and 155 (78.7%) from internship graduates. Regarding to the special habits as Khat chewing many of the participants donot chew khat and they were 131 (61.8%) from final-year and 116 (58.9%) from internship graduates. Also the majority didn't use shisha 204 (96.2%) from final-year and 185 (93.9%) from internship graduates. Those who smoke cigarettes were 15 (7.1%) from final-year and 16 (8.1%) from internship graduates. Only one participant(0.5%) from each cohort smoke electronic cigarettes. All these characteristics were not different, i.e. matched between the two cohorts except for an age difference of 2 years, marriage (relative risk = 1.82) and working status (relative risk = 3.49).

Table (2): Socio-Demographic Characteristics Analysis in Final-Year versus Internship Year, Sana'a University, Yemen, 2023

Socio-demographic		Study year		Total	p-value
Socio-demographic		Final year	Internship	Total	p-value
Sex	Male	114	100	214	0.324
	Male	53.8%	51.0%	52.4%
	Female	98	96	194
	Female	46.2%	49.0%	47.6%
Age (years)	Mean	24.76 (SD = 1.142)	26.74 (SD = 1.157)	210	< 0.0001
Age (years)	Median	25	27	195	< 0.0001
Residence with family	Yes	152	145	297	0.374
	Yes	71.7%	73.6%	72.6%
	No	60	52	112
	No	28.3%	26.4%	27.4%
Marital status	Single	179	141	320	0.001
	Single	84.4%	71.6%	78.2%
	Married	33	56	89
	Married	15.6%	28.4%	21.8%
Financial condition	Very good	57	43	100	0.260
	Very good	26.9%	21.8%	24.4%
	Good	125	116	241
	Good	59%	58.9%	59%
	Limited	30	38	68
	Limited	14.2%	19.3%	16.6%
Work beside study	Yes	13	42	55	< 0.0001
	Yes	6.1%	21.3%	13.4%
	No	199	155	354
	No	93.9%	78.7%	86.6%
Khat chewing	Yes	81	81	162	0.309
	Yes	38.2%	41.1%	39.6%
	No	131	116	247
	No	61.8%	58.9%	60.4%
Shisha	Yes	8	12	20	0.196
	Yes	3.8%	6.1%	4.9%
	No	204	185	389
	No	96.2%	93.9%	95.1%
Smoking (cigarettes)	Yes	15	16	31	0.415
	Yes	7.1%	8.1%	7.6%
	No	197	181	378
	No	92.9%	91.9%	92.4%
Electronic cigarettes	Yes	1	1	2	0.732
	Yes	0.5%	0.5%	0.5%
	No	211	196	407
	No	99.5%	99.5%	99.5%

Incidence of Depression:

Majority of the finals were depressed 157 (74.1%) as compared to 126 (64%) from internship graduates (P = 0.032). Severe (21.6%, no = 34) and extremely severe (25.5%, no = 40) depression which was greater (p = 0.015) than interns. The severe proportion among interns was 12.7% (no = 20) and the extreme severely depressed were 20.6% (no = 26) in interns.

Incidence of Anxiety

The anxious final-year medical students were 140 (66%) and 112 (56.9%) from internship graduates, while those who were normal 72 (34%) from final-year medical students and 85 (43.1%) from internship graduates. However, This difference between the two groups was not statistically significant. Severe and extremely sever anxiety among final year constituted 47.1% while sever anxiety and extremely sever among interns was 43.8% with a non-significant difference of (p = 0.206).

Incidence of Stress:

A proportion of 62.7% (n = 133) from final-year medical students were stressed and 89 (45.2%) from internship. The attributable risk is 17.5% which is statically significant (p < 0.001). moderate and extremely severe were elevated in final-year as compared to internship. As per severity of stress, both cohorts were found under stress with a small difference in extremely sever stress among students 15.8% (n = 21) versus 9% (n = 8) among interns which is a statistically significant (p = 0.004) value.

Higher incidence rates of stress, anxiety and depression was found in females of both final year and internships in comparison to males. This high incidence in females was significant in all comparisons except anxiety in final year which was insignificant (table3).

Table (3): Incidence of stress, anxiety and depression according to sex in both internship and final-year medical students in Sana'a University, Yemen, 2023 (n = 408).

Cohort		Depression No. (%)		Anxiety No. (%)		Stress No. (%)
Cohort		Yes	No	Yes	No	Yes	No
Students	M	77(67.5)	37(32.5)	69(60.5)	45(39.5)	64(56.1)	50(43.9)
Students	F	80(81.6)	18(18.4)	71(72.4)	27(27.6)	69(70.4)	29(29.6)
Significance (Pearson chi square)		0.027 (5.444)		0.081 (3.340)		0.034 (4.589)
Interns	M	52(52.0)	48(48.0)	43(43.0)	57(57.0)	36(36.0)	64(64.0)
Interns	F	73(76.0)	23(24.0)	68(70.8)	28(29.2)	53(55.2)	43(44.8)
Significance (Pearson chi square)		0.001 (12.25)		< 0.0001 (15.45)		0.01 (7.29)

Medical students in Yemen like many other countries, used to rank amongst the best 5% throughout their schooling prior to affiliation to public medical schools. They find themselves out of the competition for a seat in these highly respected schools and only the cream of the cream are offered seats. They, for first time, struggle to pass examinations with whatever a grade they get. This factor together with other factors exert a highly stressful burden which leads to stress, anxiety, and depression and probably to other psychological disorders.

Depression and anxiety are highly prevalent conditions among medical students worldwide. The prevalence of these mental disorders vary depending on the academic year, country, and other factors. According to two global meta-analysis studies, more than a third of medical students worldwide suffer from anxiety and more than a quarter suffer from depression[9, 14].

In this study, majority of the final year medical students 74% suffered from symptoms of depression, 66% from anxiety, and 62.7% from stress as measured by DASS-21. The findings indicate to high levels of depression, anxiety, and stress. These rates are greater than that reported in both meta analysis in more than two folds[9, 14]. Same high levels were found only in Egypt and Iran Studies [5, 12, 14]. These high levels in Yemen can be attributed to multifactor, including conflict that impacts and decreases socioeconomic status. Beside the resembling study conditions that exist in countries like Egypt and Iran.

Current study showed a relief attributed to graduation; in depression was 10.1%, in anxiety the relief was 9.1% while in stress was 17.5%. These findings are supported by the small proportion of students who got married and engaged in payed jobs beside their duties of internship. The highest rate of relief for example was found in stress. However, stress continued to be high (45.2%) among interns despite their graduation. These rates of relief, which are attributed to graduation are significant but not enough to be intensely reduced. Continued stresses might be linked to unpaid intern services despite the hard work they perform and the stressful conditions they face. Moreover to the uncertainty in getting a paid work opportunities in the future due to the ongoing conflict, where almost all public servants are not paid for the duties they perform. Relief in rates of depression and anxiety (10.1%, 9.1%) is considerable but not enough, probably for the same mentioned reasons of stress.

Our findings showed that female students and interns are substantially suffer from depression, anxiety and stress when compared to male colleagues. For example our female students who suffered depression symptoms were 81.6% while the male colleagues were 67.5%. This finding with the other ones of anxiety and stress in both cohorts showed a female suffering predominance like that found in Egypt, Ethiopia and Saudi Arabia [5, 11, 13]. This differences in emotional disorders are documented among females more than males due to biological and social differences[20].

In conclusion, high rates of depression, anxiety and stress symptoms were reported by final year medical students and interns with a female predominance was found. The relief of the symptoms attributed to graduation was significant in depression and stress, while insignificant for anxiety.

*Ethics approval and consent to participate: Taken from each participant and ethical clearance certificate was obtained from the Ethics Committee of the Faculty of Medicine and Health Sciences of Sana'a University.

*Consent for publication: Taken from all co-authors and volunteers were informed and agreed.

*Availability of data and material: available

*Competing interests: None.

*Funding: Not funded

* Authors' contributions:

Km and YA Supervised the research

AF,AA, MA,RH,AR,AY,GA,NA and SF participated in proposal construction, data collection and writing,
YA and AY did the analysis.
YA and AY prepared the article for publication

*Acknowledgements: NA

Author Contribution

All authors participated in proposal writing .YA and KM supervised the work.AF, AA,AA, MR, RH, AR, AY, GA, NA and SF worked in data collection and writing the dissertation for their graduation and reviewed the manuscript.YA and AY did the statistical analysis and worker in article preparaion for publication.

World Health Organization. Mental disorders. 8 June 2022. Mental disorders (who.int) accessed in 27th of Jul 2024.
Dahlin V, Joneborg N, Runeson B. Stress and depression among medical students: a cross-sectional study. Med Educ. 2005;39(6):594–604.
Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad Med. 2006;81(4):354–73.
Ibrahim AK, Kelly SJ, Adams CE, Glazebrook C. A systematic review of studies of depression prevalence in university students. J Psychiatr Res. 2013;47(3):391–400.
Abdel Wahed WY, Hassan SK. Prevalence and associated factors of stress, anxiety and depression among medical Fayoum university students. Alexandria J Med. 2017;53:77–84.
Perveen S, Kazmi SF, ur Rehman A. Relationship between negative cognitive style and depression among medical students. J Ayub Med Coll Abbottabad. 2016;28(1):94–8.
Brennan N, Corrigan O, Allard J, Archer J, Barnes R, Bleakley A, et al. The transition from medical student to junior doctor: today’s experiences of Tomorrow’s Doctors. Med Educ. 2010;44(5):449–58.
Rosen I, Gimotty P, Shea J, Bellini L. Evolution of Sleep Quantity, Sleep Deprivation, Mood Disturbances, Empathy, and Burnout among Interns. Acad Med. 2006;81(1):82–5.
Puthran R, Zhang MW, Tam WW, Ho RC. Prevalence of depression amongst medical students: A meta-analysis. Med Educ. 2016;50(4):456–68.
Mahroon ZA, Borgan SM, Kamel C, Maddison W, Royston M, Donnellan C. Factors associated with depression and anxiety symptoms among medical students in Bahrain. Acad Psychiatry. 2018;42:31–40.
Kebede MA, Anbessie B, Ayano G. Prevalence and predictors of depression and anxiety among medical students in Addis Ababa, Ethiopia. Int J Ment Health Syst. 2019;13:30.
Gabal HA, Wahdan MM, Gamal Eldin DA. Prevalence of anxiety, depression and stress among medical students, and associated factors. Egypt J Occup Med. 2022;46:55–74.
Dabbagh R, Alwatban L, Alrubaiaan M, Alharbi S, Aldahkil S, AlMuteb M, Almutairi R. Depression, stress, anxiety and burnout among undergraduate and postgraduate medical trainees in Saudi Arabia over two decades: a systematic review. Med Teach. 2023;45(5):499–509.
Tian-Ci Quek T, Wai-San Tam W, Tran X, Zhang B, Zhang M, Su-Hui Ho Z, C., and, Ho C-M. The global prevalence of anxiety among medical students: a metaanalysis. Int J Environ Res Public Health. 2019;16(15):2735.
Killinger SL, Flanagan S, Castine E, Howard KAS. Stress and depression among veterinary medical students. J Vet Med Educ. 2017;44(1):3–8.
Lovibond SH, Lovibond PF. Manual for the Depression Anxiety Stress Scales. 2nd ed. Sydney: Psychology Foundation; 1995.
Henry JD, Crawford JR. The short-form version of the Depression Anxiety Stress Scales (DASS‐21): Construct validity and normative data in a large non‐clinical sample. Br J Clin Psychol. 2005;44(2):227–39.
Dhand NK, Khatkar MS, Statulator. An online statistical calculator. Sample Size Calculator Comparing Two Indep Proportions. 2014;Accessed at 2 January 2024.
Ali AM, Green J. Depression Anxiety Stress Scale-21-Arabic Version (DASS-21). mechanisms and possible treatments. Neurophysiology. 2015;47:482–9.
AMR M, El Gilany A, El-Hawary A. Does gender predict medical students' stress in Mansoura, Egypt? Med Educ Online. 2008;13(1):4481.

No competing interests reported.

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Incidence of Depression, Anxiety and Stress among Final- Year Medical Students versus Internship Graduates of Faculty of Medicine, Sana'a University 2023

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Version 1

Abstract

INTRODUCTION

METHODS

Study Setting:

Sample Size and sampling technique:

3.8. Pilot study:

RESULTS

Socio-demographic characteristics

Incidence of Depression:

Incidence of Anxiety

Incidence of Stress:

DISCUSSION

Declarations

Author Contribution

References

Additional Declarations

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