East Asian Arch Psychiatry 2020;30:28-31 | https://doi.org/10.12809/eaap1882

ORIGINAL ARTICLE 

Mohammed Al-Maashani, MD, Psychiatry Residency Training Program, Oman Medical Specialty Board, Muscat, Oman
Naser Al-Balushi, MD, Psychiatry Residency Training Program, Oman Medical Specialty Board, Muscat, Oman
Mohammed Al-Alawi, MD, Psychiatry Residency Training Program, Oman Medical Specialty Board, Muscat, Oman; Department of Behavioral Medicine, College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman
Hassan Mirza, MD, MSc, Department of Behavioral Medicine, College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman Salim Al-Huseini, MD, Psychiatry Residency Training Program, Oman Medical Specialty Board, Muscat, Oman
Manal Al-Balushi, MD, Psychiatry Residency Training Program, Oman
Medical Specialty Board, Muscat, Oman
Yousif Obeid, MD, Department of Behavioral Medicine, College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman
Sachin Jose, MSc, Research and Statistics, Oman Medical Specialty Board, Muscat, Oman
Nasser Al-Sibani, Department of Behavioral Medicine, College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman
Samir Al-Adawi, MD, Department of Behavioral Medicine, College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman

Address for correspondence: Dr Naser Al Balushi, Psychiatry Residency Training Program, Oman Medical Specialty Board, Muscat, Sultanate of Oman. Email: naser.albalushi@hotmail.com

Submitted: 25 March 2018; Accepted: 26 March 2019

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Introduction

Psychological distress among college students is increasingly recognised.¹ However, depressive symptoms among medical students often go unrecognised, compared to the general population.² This ‘silent epidemic’ has been reported in medical schools in Gulf Cooperation Council countries.³ A meta-analysis reported that the prevalence of depressive symptoms among medical students in Gulf Cooperation Council countries was higher than the international trend.⁴ Moreover, these medical students have the highest dropout rate.⁵ In Oman, approximately 17% of medical students have depressive symptoms.⁶ The present study aimed to determine the prevalence and risk factors of depressive symptoms among medical students in Sultan Qaboos University in Oman.

Methods

This study was approved by the Ethics Committee of the College of Medicine at Sultan Qaboos University Hospital (MREC#893) and was conducted from August to December 2015 At the time of the study, there were 1041 medical students from all six academic years at the College of Medicine and Health Sciences of Sultan Qaboos University.⁷

Based on the 17% prevalence of depression among medical students in Sultan Qaboos University,⁶ the minimum sample size to have a power level of 80% was calculated as 171, with a type-1 error of 5% (alpha = 0.05) and significance level of 95%. Students were selected at random using a software randomizer; a sample of 197 was generated to allow for non-responses. Because stress level may differ among medical student year-groups,⁸ the present cohort was categorised as either pre-clinical (years 1 to 4) or clinical (years 5 to 6).

The outcome measure was the self-administered Patient Health Questionnaire-9 (PHQ-9). The PHQ-9 contains items adopted from the DSM-IV and aids in the diagnosis of depressive symptoms and their severity. It has been psychometrically validated in different settings (including primary, secondary, and tertiary), cultures, and samples. Its performance was comparable to that of doctor-administered scales in diagnosing depression. In a validation study in Oman, a cut-off score of ≥10 had a likelihood ratio of 10 for a positive test result⁹. In the present study, the same cut-off score was used for the presence of depressive symptoms. A total score of 10 to 14 was considered moderate depression, 15 to 19 moderately severe depression, and 20 to 27 severe depression, in accordance with the DSM-IV.

Those with or without depression were compared using Chi-squared test or Fisher’s exact test for categorical variables. Associations between sociodemographic and clinical variables and the presence of depression were determined using univariate and multivariate analyses. Variables associated with depression in the univariate analysis were entered into a stepwise backward logistic regression model to determine the correlates of depression and to adjust for confounders. A two-tailed significance level was set at 0.05. Statistical analysis was carried out using SPSS (Windows version 22.0; IBM Corp, Armonk [NY], United States).¹⁰

Results

Of 197 medical students selected, 189 (61 men and 128 women) responded (Table 1). Of them, 94% were single; 75.7% were preclinical students and 24.3% were clinical students. 93.7% has never diagnosed with depressive disorder. 90.5% had no family history of depressive disorder. 97.9 % has never used alcohol or opiates. According to PHQ-9 results, the prevalence of depressive symptoms was 41.3%.

In univariate analysis, female sex (p = 0.01), previous diagnosis with depression (p = 0.03), and a family history of depression (0.01) were risk factors for depression among medical students (Table 2).

In multivariate analysis, female students were more likely to develop depression than male students (adjusted odds ratio = 2.866, 95% confidence interval = 1.403-5.854, p = 0.004, Table 3). Medical students with a family history of depression were more likely to develop depression than those without a family history of depression (adjusted odds ratio = 4.150, 95% confidence interval = 1.335-12.905, p = 0.014, Table 3).

Discussion

In a meta-analysis of 167 studies from 43 countries involving 116 628 people, the prevalence of depression and depressive symptoms was 27.2%.⁸ In Oman, the prevalence has ranged from 11.4%⁶ to 27.7%.⁷ In Saudi Arabia, the prevalence was 46.2% to 48.2%.¹¹ In United Arab Emirates, the prevalence was 28.6%.¹² In Bahrain, 19%¹³ to 40%¹⁴ of medical student were reported to have depressive symptoms. In the present study, the prevalence of depressive symptoms was 41.3%. The discrepancy could be due to case ascertainment bias, heterogeneity in the methodology, the healthcare system, and cultural differences.⁸ Arab culture discourages expression of emotion. The PHQ-9 is designed to solicit the ‘cognitive’ aspect of depression rather than ‘somatic’ types, which are rife as idiom of distress in Arab populations. Nonetheless, the present study indicated that depression is rife among medical students in terms of the PHQ-9, consistent with a meta-analysis of 77 studies involving 62 728 medical students that suggested that depressive symptoms are more common among medical students in Gulf Cooperation Council countries than elsewhere.⁴

In multivariate analysis, female students had higher odds of having depressive symptoms, consistent with previous studies on the general and college populations.^4,8

Family history of depression also plays a significant role in the development of depressive symptoms, consistent with a meta-analysis that supports temporal relationship between depressive symptoms and family history of depressive illness.¹⁵ In previous studies in Gulf Cooperation Council countries, determinants of depressive illness included burnout, year of study, sex, relationship with peers, and academic performance.^11,16

This study has several limitations. First, the study was cross-sectional, so the results cannot be used to isolate the cause and effect. Second, self-administered checklists are inferior to gold-standard interview. Third, other factors were not explored such as socioeconomic status, contact with family and/or relatives, academic performance, history of re- sitting examinations or repeating, and history of self-harm. Future studies should use a more robust methodology, and other potentially modifiable factors should be investigated.

Conclusion

Depressive symptoms are common among medical students in Sultan Qaboos University. Risk factors for depressive symptoms are female sex and family history of depression.

Declaration

The authors have no conflict of interest to disclose. No financial support was received.

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