Faculty of Medicine Community Medicine Department Khartoum College of Medical Sciences 5th Year Medicine The prevalence and

determinants of depression and determinants among medical students in Khartoum College of Medical Sciences. 2013 BY: YUSRA ABUEL BASHAR ALI ADAM SUPERVISOR: DR. MUNA HASSAN MUSTAFA

List of Contents

List of Figures

Dedication
This research is dedicated to my wonderful family; especially my parents; Dr. Abuel Bashar Ali Adam and Soad Charfadine Abdelkarim, and my sister; Fatmah Abuel Bashar Ali Adam for their support and love. I truly appreciate all they have done.

Acknowledgment
First of all, I am thankful and very grateful to the dearest, most beneficial and most sincere entity to me which is the one and only my Allah, Subhanahu wa taala. Thanks to Allah for giving me a very caring and loving mother and father, and my whole family for whom I have no words to thank. A special thanks to my supervisor Dr. Muna Hassan Mustafa who despite her busy schedule has taken time to continually review my work and advise me accordingly. Her guidance, assistance, critics and encouragement saw me through this project work. Appreciation is also extended to Dr. Eman Idriss for her guidance and support to end this research. Thanks also goes to the students in the Faculty of Medicine of Khartoum College of Medical Sciences who assisted in answering my questionnaires that basically helped me carry out my research. Last but not least, thanks to the Community Department of Medicine for allowing me to do my research.

ABSTRACT
This research sets out to measure the prevalence of depression among medical students in Khartoum College of Medical Sciences at the different levels of education, taking gender differences into account. The descriptive cross-sectional research design was adopted for the study. 183 students drawn from Khartoum College Medical Sciences were involved in the study. The instrument used for the data collection was a questionnaire developed by the World Health Organization, slightly modified. The instrument had face validity due to the input of the supervisor and other relevant professionals to the instrument. The outcome of the study shows that the prevalence of depression of all types was found among 71% of the students, while the severe type of depression was found among 36% of the students. The prevalence of depression among year 1 medical students was 80%, among year 3 medical students was 60% and among year 6 medical students was 74%. The association between the levels of education of medical students and the prevalence of depression was statistically significant (p value=0.0000). The female students had a higher rating when compared to their male counter parts (Female 75%; Male 66%); the difference was statistically significant (p value=0.0004). The findings of this study have serious implications for the training and retention of medical doctors in Khartoum College of Medical Sciences. It is therefore recommended that further and a more comprehensive study in this direction be carried.

CHAPTER 1

INTRODUCTION
There isnt a universally accepted definition for depression. However, it is possible to describe this behavioral condition. Depression is a mood disorder that manifests itself in various ways (Rathus & Nevid, 1991). According to Beck (1967) depression can negatively influence a persons motivation, affect, cognition and physiology. Depression is a state in which a person is in low mood and with aversion to activity having a negative effect on a persons thoughts, behavior, feelings, physical well-being and world view. Depressed people usually experience feelings of sadness, emptiness, loss of hope, irritability, restlessness, fatigue, helplessness, worthlessness, guilt, hurt, anxiousness and worry. They have problems concentrating, making decisions and remembering details, experience either a loss in appetite or overeating, lose interest in activities which were once pleasurable for them and over time may contemplate or attempt suicide. Depressed mood is not necessarily a psychiatric disorder. It can either be a normal reaction to certain life events, a symptom of some medical conditions or a side effect of some medical treatments. Recent studies have highlighted a problem a lot of medical students are familiar with, which is the prevalence of depression during medical education and training; however estimates of its prevalence vary. Medical education is perceived as being stressful. It is characterized by many psychological changes in students. Medical students encounter multiple anxieties in transformation from insecure student to young knowledgeable physician. There is a growing concern about stress in medical training. Studies have observed that, during their undergraduate course, medical students experience a high incidence of personal distress. High levels of stress may have a negative effect on mastery of the academic curriculum. Stress, health and emotional problems increase during the period of undergraduate medical education. This has a negative impact on cognitive functioning and learning and can lead to mental distress. [1] The majority of medical schools, the environment itself is an all prevailing pressure providing an authoritarian and rigid system; one that encourages

competition rather than cooperation between learners. Studies suggest that mental health worsens after student begins medical school and remains poor throughout training. It is not just undergraduate study period part which brings the stress but it may continue later in internship, postgraduate study period and later in physicians practical life. It can also reach a point of burnout level. The estimated prevalence of emotional disturbance was found in different studies higher than in general population. In a study done at three British universities, the prevalence of stress was 31.2%, in a Malaysian medical school 41.9% and 61.4% is a Thai medical school. Medical school stress is likely to predict later mental health problems, but unfortunately, students seldom seek help for their problems. In a Swedish study, the prevalence of depressive symptoms among students was 12.9% and a total of 2.7% of students had made suicidal attempts. Studies from different parts of the world have shown that the rates of depression and suicide attempts are higher in medical students and that these rates usually continue to remain elevated when these students become physicians. [2] Depression levels in the community are considered as specific indicators for mental status of a person, however, usually females experience it more than males usually due to their puberty manifestations. [3] It is important for medical educators to know the prevalence of depression, which not only affects their health, but also their academic achievement at different time points of their study period. There should be a system to identify the prevalence of their training and to specify the relevant contributing factors. This knowledge can assist in instituting specific interventions. An extensive electronic internet based search failed to locate any study which shows the prevalence of depression in undergraduate medical students in Sudan.

Objectives of the studyGeneral Objective: To measure the prevalence and determinants of depression among medical students in Khartoum College of Medical Sciences. Specific Objectives: To determine the prevalence of depression amongst the medical students at Khartoum College of Medical Sciences. To determine the effect of gender and the level of education on depression.

CHAPTER 2

LITERATURE REVIEW
The high incidence of depressive symptoms in medical students is worrying therefore, screening for and treatment of depression among medical students is necessary. Only in the past two decades has depression in adolescents been taken seriously. Depression is an illness that involves the body, mood and thoughts. It affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. Therefore it comes to no surprise to discover that adolescent depression is strongly linked to teen suicide. Adolescent suicide is now responsible for more deaths in youths aged 15 to 19 than cardiovascular disease or cancer. Depression in this age group is greatly under diagnosed and can lead to serious difficulties in school, work and personal judgments, despite these alarming increased suicide rates, which if left untreated may continue into adulthood. The reason why depression is often overlooked in adolescents is because it is a time of rebellion, emotional turmoil, mood swings, gloomy thoughts, and heightened sensitivity. Blackman (1996), observed that the challenge is to identify depressive symptomatology which may be superimposed on the backdrop of a more transient, but expected developmental storm. [4] Unlike adult depression, symptoms of youth depression are often masked. Instead of expressing sadness, teenagers may express boredom and irritability, or may choose to engage in risky behaviors, which may lead to serious consequences in the future such as a form of drug abuse or addiction. Psychological well-being is important for medical students, for the patients they meet and for their future medical practice. Medical students with depression more commonly consider dropping out of their course. [5] However, the prevalence of depression among medical students varies, depending on level of education and gender differences. Among medical students, academic stressors include the volume of material to be learned, academic performance and evaluation (examination and continuous assessment). Academically less successful students reported somewhat higher

levels of depressive ideation and symptomatology. The potential negative effects of emotional distress on medical students include impairment of functioning in classroom performance and clinical practice, stress-induced disorders and deteriorating performance. Students in extreme stress or depression need serious attention , otherwise inability to cope successfully with the enormous stress of education may lead to a cascade of consequences at both personal and professional levels. Brown, 1996, stated that the key indicators of adolescent depression include a drastic change in eating and sleeping patterns, significant loss of interest in previous activity interests, constant boredom, disruptive behavior, peer problems, increased irritability and aggression. [2] What usually causes a person to become depressed? For many kids, symptoms of depression are directly related to low self-esteem stemming from increased emphasis on peer popularity. For other kids, depression arises from poor family relations, which could include decreased family support and perceived rejection by parents. Oster and Montgomery (1996), stated that when parents are struggling over marital or career problems, or are ill themselves, teens may feel the tension and try to distract their parents. This distraction could include increased disruptive behavior, self-inflicted isolation and even verbal threats of suicide. Many times parents are so wrapped up with their own conflicts and busy lives that they fail to see the changes in their teens, or they simply refuse to admit their teen has a problem. In todays society the family unit can be quite different from the stereo typical one, where the father went to work and the mom was the homemaker. Today, with single parent families and families where both parents have corporate jobs, the teen may feel he or she is playing second fiddle in importance in the lives of their parents. Also, great stress is placed upon teens today starting in early childhood. At one end of the spectrum, teens maybe pushed by their parents to excel in sports and scholastics, and at the other end there are teens that are never given direction or aspirations by their parents. Those pressured to excel may become overwhelmed by what is expected of them and can fall into using drugs and alcohol as a form of escape and may feel the only way out is that of suicide. On the other hand those teens without direction and lack of interest on the part of their parents, may also turn

to drugs and alcohol as a means of escape. They may contemplate and even attempt suicide as a way of either drawing attention to themselves or to just end their lives because no cares about them anyway. These disorders are likely based on a complex interplay of biological/genetic forces and developmental transactions between teens, family members and the outside world. Some teens manage to survive and even flourish under the most difficult circumstances, while others flounder under the same conditions. An estimated 2,000 teenagers per year commit suicide in the United States, making it the leading cause of death after accidents and homicide. [4] Blackman (1995) stated that it is not uncommon for young people to be preoccupied with issues of mortality and contemplate the effect their death would have on close family and friends. The term depression has been used in adolescent research (Compas, Grant, & Ey, 1995) to refer to a continuum of affective disturbances that include dysphoric mood, a syndrome or cluster of symptoms of psychological distress, and psychiatric disorders such as major depressive episodes (MDEs) that are classied according to diagnostic criteria. Symptoms of depression may interfere with adolescents abilities to engage effectively in stagesalient tasks, thereby potentially leading to negative lifelong consequences for physical and psychological health and wellbeing. For example, depression in adolescence has been linked to problems with work, stressful life events, early pregnancy, smoking, and substance abuse. [6] The intensity of any psychological/psychiatric disorder such as depression may vary on a continuum or scale ranging from mild/partial (through moderate and severe) to extreme, profound or catastrophic condition. A condition that is extreme, profound or catastrophic is often disabling and the affected person might not function in the normal way without suitable professional intervention. [7] Prevalence incidences in student populations Research indicates that there is now an increase in the incidence of depression in college and university students including all categories of trainee teachers. The main cause of depression is stress. It doesnt matter how much or how little stress

you have, all of it can lead to depression. Stress doesn't automatically mean depression. Some people can handle stress just fine, and others, it can be the littlest thing and it will just nag and nag at them, until they can't handle it anymore. They start to feel down, and negative about themselves. That's when it becomes a problem. Depressed adolescents are also at risk for anxiety, conduct disorders, as well as academic failure and problems in interpersonal relationships. Depression, stress and anxiety appear to be linked to each other but the connections have only been determined correlationally and not experimentally. One possible reason why depression, anxiety and stress might co-exist may be due to the fact that they share a few common symptoms, causes and effects. [5] Being clinically depressed is very different from the down type of feeling that all people experience from time to time. Occasional feelings of sadness are a normal part of life, and it is unfortunate that such feelings are often referred to as "depression." In clinical depression, such feelings are out of proportion to any external causes. There are things in everyone's life that are possible causes of sadness, but people who are not depressed manage to cope with these things without becoming incapacitated. As one might expect, depression can present itself as feeling sad or "having the blues". However, sadness may not always be the dominant feeling of a depressed person. Depression can also be experienced as a numb or empty feeling, or perhaps no awareness of feeling at all. A depressed person may experience a noticeable loss in their ability to feel pleasure about anything. Depression, as viewed by psychiatrists, is an illness in which a person experiences a marked change in their mood and in the way they view themselves and the world. Depression as a significant depressive disorder ranges from short in duration and mild to long term and very severe, even life threatening. Depressive disorders come in different forms, just as do other illnesses such as heart disease. The three most prevalent forms are major depression, dysthymia, and bipolar disorder. [8] In its mildest form, depression can mean just being in low spirits. It doesnt stop you leading your normal life, but makes everything harder to do and seem less worthwhile. At its most severe, major depression (clinical depression) can be life-

threatening, because it can make you feel suicidal or simply give up the will to live. Types of Depressive Illnesses: It is important to keep in mind that depression comes in many different faces. There are different kinds of illnesses from depression: Major Depression Major depression is manifested by a combination of symptoms (see symptom list below) that interfere with the ability to work, sleep, eat; and enjoy oncepleasurable activities. These disabling episodes of depression can occur once, twice, or several times in a lifetime. [8] Dysthymia A less severe type of depression, dysthymia, involves long-term, chronic symptoms that do not disable, but keep you from functioning at "full steam" or from feeling good. Sometimes people with dysthymia also experience major depressive episodes. [8] Bipolar Depression (manic-depressive illness) Another type of depressive disorder is manic-depressive illness, also called bipolar depression. Not nearly as prevalent as other forms of depressive disorders, manic depressive illness involves cycles of depression and elation or mania. Sometimes the mood switches are dramatic and rapid, but most often they are gradual. When in the depressed cycle, you can have any or all of the symptoms of a depressive disorder. When in the manic cycle, any or all symptoms listed under mania may be experienced. Mania often affects thinking, judgment, and social behavior in ways that cause serious problems and embarrassment. For example, unwise business or financial decisions may be made when in a manic phase. [8] Seasonal Affective Disorder (SAD) SAD is a pattern of depressive illness in which symptoms recur every winter. This form of depressive illness often is accompanied by such symptoms as marked decrease in energy, increased need for sleep, and carbohydrate craving. Photo

therapy - morning exposure to bright, full spectrum light - can often be dramatically helpful. [8] Genetic Depression A recent study showed the embryo's brain is in fact highly developed, and that at six and seven months, the embryo is already learning to hear, see, and feel. Dr. Verny, co-author of "The Secret life of the Unborn Child", believes that mother to child bonding actually begins in the womb. Dr. Verny has a theory that the embryo can in fact have emotional problems, that come from the mother. How can this be? Dr. Verny explains, since the mother and the baby share everything, if the mother becomes depressed the baby can feel it. Since depression is a chemical off-balance in the head, the hormones that are in the blood stream are affected too. The imbalance hormones, travel to the baby through the blood, and thus the baby receives the hormones. Now the baby's hormones are imbalanced and the baby becomes depressed too. The baby can stay depressed in the womb, and even after its born. [9] How is bereavement different from depression? A full depressive syndrome frequently is a normal reaction to the death of a loved one (bereavement), with feelings of depression and such associated symptoms as poor appetite, weight loss, and insomnia. However, morbid preoccupation with worthlessness, prolonged and marked functional impairment, and marked psychomotor retardation are uncommon and suggest that the bereavement is complicated by the development of a Major Depression. The duration of "normal" bereavement varies considerably among different cultural groups. [4] Endogenous Depression A depression is said to be endogenous if it occurs without a particular bad event, stressful situation or other definite, outside cause being present in the person's life. Endogenous depression usually responds well to medication. Some authorities do not consider this to be a useful diagnostic category. [4] Environmental Depression Depression does not result only from psychological and genetic matters. But in fact depression can also come from an environment. If a child's sibling is

depressed, or a parent, the child becomes used to this depressive life, and slowly becomes depressed too. The child could be perfectly happy, but because he/she is continually surrounded by depression, it becomes a way of life for the child too. [9] Atypical Depression "Atypical depression" is not an official diagnostic category, but it is often discussed informally. A person suffering from atypical depression generally has increased appetite and sleeps more than usual. A atypical depressive person may also be able to enjoy pleasurable circumstances despite being unable to seek out such circumstances. This contrasts with the "typical" depressive, who generally has reduced appetite and insomnia, and who is often unable to find pleasure in anything. Despite its name, atypical depression may in fact be more common than the other kind. [4]

The typical Symptoms of Depression A depressive disorder is a "whole-body" illness, involving your body, mood, and thoughts. It affects the way you eat and sleep, the way you feel about yourself, and the way you think about things. A depressive disorder is not a passing blue mood, neither is it a sign of personal weakness or a condition that can be willed or wished away. People with a depressive illness cannot merely "pull themselves together" and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help over 80% of those who suffer from depression. Bipolar depression includes periods of high or mania. Not everyone who is depressed or manic experiences every symptom. Some people experience a few symptoms, some many. Also, severity of symptoms varies with individuals. [4] Symptoms of Depression: Persistent sad, anxious, or "empty" mood Feelings of hopelessness, pessimism Feelings of guilt, worthlessness, helplessness Loss of interest or pleasure in hobbies and activities that you once enjoyed

 Insomnia, early-morning awakening, or oversleeping Appetite and/or weight loss or overeating and weight gain Decreased energy; fatigue, being "slowed down" Thoughts of death or suicide, suicide attempts Restlessness, irritability Difficulty concentrating, remembering, making decisions Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and chronic pain Upset Stomach/Nausea: most everybody, when thinking of depression thinks of a mental and emotional disease. When in fact it can cause psychical pain, such as pain in the stomach and nausea. [4]

The Diagnostic Criteria for Depression Depression comes in many forms and in many degrees. Below, are some of the most common depressive types, along with some of the diagnostic criteria from the DSM-III-R (the official diagnostic and statistical manual for psychiatric illnesses). [4] Major Depression: This is a most serious type of depression. Many people with major depression cannot continue to function normally. The treatments for this are medication, psychotherapy and, in extreme cases, electroconvulsive therapy (ECT). [4] Diagnostic criteria: At least five of the following symptoms have been present during the same twoweek period and represent a change from previous functioning; 1. At least one of the symptoms is either depressed mood, or loss of interest or pleasure. (Do not include symptoms that are clearly due to a physical condition, mood-incongruent delusions or hallucinations, incoherence, or marked loosening of associations.) Depressed mood most of the day, nearly

every day, as indicated either by subjective account or observation by others 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated either by subjective account or observation by others of apathy most of the time). 3. Significant weight loss or weight gain when not dieting (e.g. more than 5% of body weight in a month). 4. Decrease or increase in appetite nearly every day. 5. Insomnia or hypersomnia nearly every day. 6. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). 7. Fatigue or loss of energy nearly every day. 8. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick). 9. Diminished ability to think or concentrate, or indecisiveness nearly every day (either by subjective account or as observed by others). 10.Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. [4] It cannot be established that an organic factor initiated and maintained the disturbance. The disturbance is not a normal reaction to the death of a loved one. At no time during the disturbance have there been delusions or hallucinations for as long as two weeks in the absence of prominent mood symptoms (i.e. before the mood symptoms developed or after they have remitted). Not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder. [4] Dysthymia: This is a mild, chronic depression which lasts for two years or longer. Most people with this disorder continue to function at work or school but often with the feeling that they are "just going through the motions". The person may not

realize that they are depressed. Anti-depressants or psychotherapy can help. [4] Diagnostic criteria: Depressed mood (or can be irritable mood in children and adolescents) for most of the day, more days than not, as indicated either by subjective account or observation by others, for at least two years (one year for children and adolescents) Presence, while depressed, of at least two of the following: 1. 2. 3. 4. 5. 6. Poor appetite or overeating Insomnia or hypersomnia Low energy or fatigue Low self-esteem Poor concentration or difficult making decisions Feelings of hopelessness during a two-year period (one-year for children and adolescents) of the disturbance, never without the symptoms in '1.' for more than two months at a time. 7. No evidence of an unequivocal Major Depressive Episode during the first two years (one year for children and adolescents) of the disturbance. 8. Has never had a Manic Episode or an unequivocal Hypomanic Episode. Not superimposed on a chronic psychotic disorder, such as Schizophrenia or Delusional Disorder. [4]

It cannot be established that an organic factor initiated or maintained the disturbance, e.g., prolonged administration of an antihypertensive medication. Adjustment Disorder with Depressed Mood: This is the type of depression that results when a person has something bad happen to them that depresses them. For example, loss of one's job can cause this type of depression. It generally fades as time passes and the person gets over whatever it was that happened. [4]

Diagnostic criteria: A reaction to an identifiable psycho social stressor (or multiple stressors) that occurs within three months of onset of the stressor(s). The maladaptive nature of the reaction is indicated by either of the following: 1. Impairment in occupational (including school) functioning or in usual social activities or relationships with others. 2. Symptoms that are in excess of a normal and expectable reaction to the stressor(s). The disturbance is not merely one instance of a pattern of overreaction to stress or an exacerbation of one of the mental disorders previously described (in the entire DSM). The maladaptive reaction has persisted for no longer than six months. The disturbance does not meet criteria for any specific mental disorder and does nor represent Uncomplicated Bereavement. [4] Risks of Depression: There are a lot of risks when dealing with depression. From eating disorders to suicide, depression should not be taken lightly. All types of depression is serious from the smallest case to the severest, depression is dangerous, because your emotions and thinking are off track. People of all ages are at risk to depression. Teens are more likely to develop a case of depression than adults, because their hormones are already off balance. People who have lost a loved one, or have had a traumatic experience are also high at risk. Problems with school, stressful family life or relocation to a new community are all risk factors. The following are also risk factors:Eating Disorders: This is a very common risk in teenagers, because depression makes you feel bad, you start to look at yourself differently, and this is not always good. Often, at times teenagers look at their body and see things that aren't really there. They picture themselves heavy and feel that the cause of their depression is their weight and that if they could lose the weight they would be happy. Many victims of eating disorders don't realize what they're doing to themselves, they don't see the bodily harm. [9]

Bulimia: This disorder is when the victim, binges, or overeats, and then makes themselves vomit, in an attempt to get rid of the food. This disorder is very serious, and can result in hospitalization if not treated properly. This illness most often affects teenage girls, who are already worried about their body. [9] Anorexia: This is the most serious of eating disorders. The victim thinks that they are really fat, and that they have to lose weight. Most of the time the victim is already thin but can't see it. The victim then tells herself that she has to lose weight, and that starvation is the only answer. This is very serious because it can start from a healthy diet, to not eating at all. If anorexia is not treated in the beginning, it can become deadly. [9] Self-Injury: Depression is all about feelings, and how you see yourself. Some teenagers don't know how to express their feelings so they just keep them bottled up. That's when their emotions are dangerous. Because they don't talk to anyone, they need another way of letting their emotions out, so they most often turn to self-injury. Victims don't know how else to let their emotions out so they turn to pain as the answer. Many depressed teenagers think that they were bad, and that's why their depressed. When they hurt themselves in anyway, they feel as though they deserve to be punished and that the pain feels good. There are several different ways of self-injury, some are burning yourself, hitting things, and the most popular is slicing your wrists. These can all be deadly if not treated. [9] Suicide: Suicide is the most serious risk of depression. Many people who are depressed look to suicide as a way out of their pain. They feel as if they at the end of their rope and have nowhere to turn except suicide. [9]

Depression and College/University Students Depression effects 76 out of a 100 college students, which are mainly freshmen entering a new world so to speak. Often times you wont see it right away or not at all. This is an age group thats tricky, states a psychologist at Davidson College in North Carolina, DeWitt Crosby said, They are adults by law, but theyre still dealing with making decisions on their own. Often times the only funding is for counselors who will perform a scattershot therapy. They don't actually treat what is wrong, but try to cover many possibilities of what could be wrong within a short period of time. USA TODAY states in a recent study that 14% of the 701 students who took a survey in the Boston area showed significant symptoms of depression, and over half of them could qualify as having major depression. If treatment of the depression was sought, at least 80% would get better. The National Survey of Counseling Center Directors reported an 85% increase in severe psychological problems over the past five years. Also 30% reported at least one student suicide on their campus within the last (2001/2002) school year. [10] Causes of depression in medical students: The causes of depression in medical students are many and can be varied. In addition the causal factors may be categorized as being either internal (genetic/hereditary or external (environmental). This includes the following as the main causative factors for depression in medical students: [5] Separation from family and transitioning from home to university environment Increased academic workload and demands Challenges of living independently for the first time Financial problems, crises and responsibilities Peer pressure Being stalked, sexual assault / harassment and rape (for females) Culture shock due to cultural differences (for foreign students) Relationship problems (social-interpersonal)

 Unrealistic expectations of students and their parents (e.g. perfectionism and the all-or nothing thinking mentality) Poor time management Drugs, alcohol, and lack of adequate sleep Negative self-interpretation or appraisal and low self-esteem Daily hassles of doing course work Assignment papers, mid-term tests, projects and final examinations Global mental health of medical students In studies that investigated mental health in a more global fashion, medical students tend to have greater overall psychological distress than is found in the general population. In two separate studies at the University of Calgary Faculty of Medicine, Toews et al. reported total GSI scores on the SCL-90-R and SCL-90 among first- to fourth-year medical students that were higher than those for population norms. In a survey of 703 first- and second-year students at the University of Washington School of Medicine conducted in the spring annually between 1980 and 1983 (response rate 86%), 151 (25%) students had SCL-90 scores above the 98th percentile of non-patient norms. Lloyd et al. and Henning et al. reported similar findings. [11] Lower prevalence of depression in Asian countries than in Western countries has been consistently reported by previous studies. Cross-cultural differences may influence how people experience and evaluate depressive symptoms, contributing to the differences in depression prevalence among countries. For instance, Koreans have shown a higher diagnostic threshold for major depressive disorder (MDD) than do Americans, which results in a lower prevalence of MDD in epidemiological studies. In addition, Koreans showed different symptom patterns. They are more likely to express symptoms of low energy and difficulty with concentration but are less likely to express depressed mood and ideations about death than Americans. Therefore, it can be supposed that the prevalence, possible risk factors, and consequences of depression for Korean medical students are likely to differ from those for their Western counterparts. [11]

Depression is a highly treatable problem that often goes undiagnosed or is attributed to the stresses and strains of daily life. Because the consequences of depression for adolescents can be severe, understanding the development of depression in males and females during adolescence and the factors that inuence the trajectories are critical to efforts that aim to prevent the emergence of depression and its debilitating effects on the wellbeing. [11]

CHAPTER 3

METHODOLOGY
Study Design The study adopted a descriptive cross sectional community based approach. Study Area The investigation was carried out in the Faculty of Medicine, at the Khartoum College of Medical Sciences, Khartoum City, Sudan. KCM has faculties of Medicine, Pharmacy, Dentistry and Laboratory Sciences with a total number of 613 undergraduate students in the Faculty of Medicine of Years 1, 2, 3, 4, 5 and 6. Study Population In this study, student participants from the Faculty of Medicine; registered students in Years 1, 3 and 6 were enrolled in the study (n = 183) in 2013. Participants enrolled in the study: Including- Students under the Faculty of Medicine; in Years 1, 3 and 6 were enrolled in the study (n=183). Excluding- Students in Years 2, 4 and 5 under the Faculty of Medicine and all the students who are in the rest of the faculties. Sampling Method The study population was stratified according to the different levels of education, which are Years 1, 3 and 6. Out of this number 50% were male and 50% were female. The study population was stratified according to the different levels of education, which are Years 1, 3 and 6. Stratified Simple Random Sampling was applied and subjects were selected randomly from each stratum; 61 students were randomly selected from each Year.

Sample Size The sample size was calculated by the following formula:

n=

z x p x q x N d (N-1) + z x p x q

Variable values:

p = 0.5

q = 1-p

N = 352 students (total population) z = 1.96 d = 0.05

The sample size (n) = 183 students

Data Collection Methods A self-administered questionnaire was given to the medical students, who were present in the class at the time of distribution and were willing to participate in the study. The survey was done at a time when the students did not have any major examination scheduled yet. The instrument used to asses the depression levels was The Major Depression Inventory (MDI), a self-report mood questionnaire developed by the World Health Organization, slightly modified to include socio-demographic variables such as gender and level of education as to determine the relationship between socioeconomic variables and the prevalence of depression. The first part of the questionnaire included socio-demographic variables such as gender, level of education and age group, while the second part

of the questionnaire asked about how they have been feeling over the past two weeks, for the assessment on the degree of depression. The Major Depression Inventory (MDI) self-report mood questionnaire was constructed by a team led by Professor Per Bech, a psychiatrist based at Frederiksborg General Hospital in Denmark. The MDI differs from many other self-report inventories, such as the Beck Depression Inventory (BDI), because it is able to generate an ICD-10 or DSM-IV diagnosis of depression in addition to an estimate of symptom severity. It has a high internal consistency as well as all its questions are significantly related to the total score and questions inquiring about psychiatric issues are significantly related to each other. These are desirable attributes of the questionnaire, which make it reliable, valid and generalisable. [7] Procedure for data collection: As a depression rating scale As a severity measure, the MDI score ranges from 0 to 50, since each of the 10 items can be scored from 0 (at no time) to 5 (all the time). Again, for items 8 and 10, alternative a or b with the highest score is considered. [7] Mild depression Moderate depression Severe depression MDI total score of 20 to 24 MDI total score of 25 to 29 MDI total score of 30 or more

To ensure anonymity, the respondents were asked not to put names or other identifying notation on the questionnaire. Data Management and Analysis The data was managed and analyzed using a computer program called Statistical Package for Social Sciences (S.P.S.S). Regarding ethical concerns, an informed consent was taken verbally from all people involved.

CHAPTER 4

RESULTS
There were 352 students altogether in Years 1, 3 and 6 MBBS. Of these 183 (52%) medical students were enrolled in the study (n=183). Among them 176 (50%) were males and 176 (50%) were females.

Table 1- The table below shows the distribution of the study sample according to the background characteristics, Khartoum Collage of Medical Sciences, 2013 (N=183) . Variables Educational Level (n=183) Year 1 Year 3 Year 6 Gender Male Female 86 97 66 75 61 61 61 80 60 74 Frequency Percentage

The prevalence of depression among the study population above for Year 1 medical students is (80%), Year 3 medical students is (60%) and Year 6 medical students is (74%) and, in Males is (66%) and in Females is (75%).

Table 2- The table below shows the distribution of the degree of depression among medical students. Degree of Depression Not Depressed Mild Depression Moderate Depression Severe Depression Total Frequency 53 22 42 66 183 Prevalence (%) 29 12 23 36 100

Comment [a1]: Complete the title as in table 1

The distribution of the degree of depression among the study population above is 29% Not Depressed, 12% Mild Depression, 23% Moderate Depression and 36% Severe Depression.

Figure No.1:- The distribution of the degree of depression among Year 1 medical students.

Year 1 Medical Students

35 30 25 20 15 10 5 0 Not Depressed Mild Depression Moderate Depression Severe depression Degree of Depression

The degree of depression among the study population abovefirst year student is (20%) Not Depressed, (16%) Mild Depression, (31%) Moderate Depression and (33%) Severe Depression. Figure No.2:- The distribution of the degree of depression among Year 3 medical students.

Year 3 Medical Students

45 40 35 30 25 20 15 10 5 0 Not Depressed Mild Depression Moderate Depression Severe Depression Degree of Depression

The degree of depression among the study populationthird year students above is (40%) Not Depressed, (10%) Mild Depression, (15%) Moderate Depression and (35%) Severe Depression. Figure No.3:- The distribution of the degree of depression among Year 6 medical students.

Year 6 Medical Students

45 40 35 30 25 20 15 10 5 0 Not Depressed Mild Depression Moderate Depression Severe Depression Degree of Depression

The degree of depression among the study populationsixth year students above is (26%) Not Depressed, (10%) Mild Depression, (23%) Moderate Depression and (41%) Severe Depression. Figure No.4:- The distribution of the degree of depression among the medical students.
40 35 30 25 20 15 10 5 0 Not Depressed Mild Depression Moderate Depression Severe Depression Degree of Depression

The distribution of the degree of depression among the study population above is 29% Not Depressed, 12% Mild Depression, 23% Moderate Depression and 36% Severe Depression.

Table 3- The table below shows the prevalence of depression among the different levels of education. Year 1 Depressed Not Depressed 49 (80%) 12 (20%) Year 3 36 (60%) 25 (40%) Year 6 45 (74%) 16 (26%)

Chi square=119.9 p value=0.0000

The prevalence of depression among the study population above is more among for Year 1 medical students is (80%), followed by year 6 students (74%) then Year 3 medical students is (60%) and Year 6 medical students is (74%).. The difference was statistically significant (p value = 0.000) Figure No.5:- The distribution of the degree of depression among the different levels of education.
45 40 35 30 25 20 15 10 5 0 Year 1 Year 3 Year 6 Mild Depression Moderate Depression Severe Depression

The degree of depression among the study population above for Year 1 medical students is (16%) Mild Depression, (31%) Moderate Depression, (33%) Severe Depression. For Year 3 medical students is (10%) Mild Depression, (15%) Moderate Depression and (35%) Severe Depression. For Year 6 medical students is (10%) Mild Depression, (23%) Moderate Depression and (41%) Severe Depression.

Figure No.6:- The prevalence of depression among the different levels of education.
90 80 70 60 50 40 30 20 10 0 Year 1 Year 3 Year 6 Prevalence of Depression

The prevalence of depression among the study population above for Year 1 medical students is (80%), Year 3 medical students is (60%) and Year 6 medical students is (74%). Table 4- The table below shows the prevalence of depression between the two genders. Males Depressed Not Depressed 57 (66%) 29 (34%) Females 73 (75%) 24 (25%)

Chi square=54.4 p value=0.0004 The prevalence of depression among the study population above in less among Males is (66%) and incompared to Females is (75%). The difference was statistically significant (p value = 0.000)

Figure No.7:- The distribution of the degree of depression between the two genders.
45 40 35 30 25 20 15 10 5 0 Males Females Mild Depression Moderate Depression Severe Depression

The degree of depression among the study population above in Males is (14%) Mild Depression, (23%) Moderate Depression and (29%) Severe Depression and in Females is (10%) Mild Depression, (23%) Moderate Depression and (42%) Severe Depression.

Figure No.8:- The prevalence of depression between the two genders.

76 74 72 70 68 66 64 62 60 Males Females Prevalence of Depression

The prevalence of depression among the study population above in Males is (66%) and in Females is (75%).

CHAPTER 5

DISCUSSION
The prevalence of depression in Khartoum College of Medical Sciences was found among 71% of the medical students, while the severe type of depression was found among 36% of the medical students. In a similar study in Karachi, there were 252 students in 4th year MBBS to 1st year MBBS. Of these 189 were present during the survey. Using the depression scale it was found out that 113 (60%) students had depression. [12] The degree of depression for Year 1 medical students was (16%) mild depression, (31%) moderate depression, (33%) severe depression. For Year 3 medical students was (10%) mild depression, (15%) moderate depression and (35%) severe depression and for Year 6 medical students was (10%) mild depression, (23%) moderate depression and (41%) severe depression. The outcome of the study shows that the prevalence of depression among Year 1 medical students was 80%, among Year 3 medical students was 60% and among Year 6 medical students was 74%. The result clearly indicates that the Year 1 medical students had the highest rate of depression. In a previous study, it is seen that prevalence of anxiety and depression was high among newly entered students (1st and 2nd year) as compared to students who have cleared the first professional examination (3rd and 4th year), which could be due to stress of new study environment. [12] However, among the medical students diagnosed with severe depression, the Year 6 students had the highest rate of severe depression41%. The association between the level of education and the prevalence of depression was statistically significant (p=0.000). The association between the level of education and the prevalence of depression data supports the view that, upon entering medical school, the rise in depression scores and their persistence over time suggest that the prevalence of depression during medical school is chronic and persistent rather than episodic. The findings suggest that first-year students in Khartoum College of Medical Sciences are a vulnerable group and need more attention to help them make smooth transitions between

premedical and medical curricula. Also, the females had more significant increases in depression scores than did the males. There was a difference in the prevalence of depression between the female students when compared to their male counter parts (Female 75%; Male 66%). 75% of the female students were depressed and 66% of the male students were depressed. From this result it was clear that the prevalence of depression among the female medical students was higher than that of the male students. Western data suggest that females experience high levels of stress as compared to males. [12] This study highlighted the possible risk factors of MDD among medical students and pervasive association of depression with poor functioning. This means that the prevalence of depression may adversely impact professionalism and patient care; exploration of depression among medical students would lead to useful insights into this problem. The findings confirm that the medical students in Khartoum College of Medical Sciences experience a widespread form of depression, the findings are consistent with other western studies, however, there is no local data available to support our findings. Future studies are needed to explore causes, consequences, and solutions for this problem rather than simply chronicling the problem.

CHAPTER 6

CONCLUSION
Although medical schools are responsible for graduating competent and healthy physicians, the findings demonstrate that a large number of students frequently experience depression during medical school. The prevalence of depression in Khartoum College of Medical Sciences was found among 71% of the medical students, while the severe type of depression was found among 36% of the medical students. The outcome of the study shows that the prevalence of depression among Year 1 medical students was 80%, among Year 3 medical students was 60% and among Year 6 medical students was 74%. The result clearly indicates that the Year 1 medical students had the highest rate of depression The difference was statistically significant (p value = 0.000). The results of the study showed that there was a difference in the prevalence of depression among the male and female medical students. The female students had a higher rating when compared to their male counter parts (Female 75%; Male 66%) The difference was statistically significant (p value = 0.000) . From this result it was clear that the prevalence of depression among the female medical students was higher than that of the male students. These findings show that a high rate of depression exists among the medical students in Khartoum College of Medical Sciences, which suggests that when students are taken into colleges, special care has to be taken to find out obvious depression problems or just psychological distress in them.

CHAPTER 7

RECOMMENDATIONS
The study findings highlight the need of psychiatric counseling and support services available to vulnerable students. These findings should be further explored in longitudinal studies to identify the stressors leading to these outcomes and appropriate interventions. The right therapy should be chosen by a professional in order for depression to be curable. High levels of depression was found among our medical students in Khartoum College of Medical Sciences. This poses additional challenges for students support services delivery which may require to address mental health problems along with common health strategies for our students. It is important for medical educators to know the prevalence and causes of student distress, which not only affects a students health, but also their academic achievement at different time points of their study period. Khartoum College of Medical Sciences should encourage programs to take a comprehensive approach to fostering and promoting well-being among their medical students. With the help of parents, teachers, mental health professionals and other caring adults, the severity of a students depression can not only be accurately evaluated, but plans made to improve his or her well-being and ability to fully live life. Efforts to improve the well-being of students must go beyond prevention of and assessment for depression; follow-up studies for monitoring prevalence of depression and attention to other forms of student distress, including burnout, fatigue, and anxiety/stress will help in instituting intervention strategies.

 There should be a system to identify the prevalence of their training and to specify the relevant contributing factors. This knowledge can assist in instituting specific interventions. Additional research to improve our understanding of the causes and consequences of the prevalence of depression among medical students, and to investigate potential solutions, is likely to benefit not only the affected individuals, but also the patients for whom they provide care.

REFERENCES
1. Deborah Goebert, DrPH, Junji Takeshita, MD, Medical students and depression. Academic Medicine, Vol. 84, No. 8 / August 2009. 2. Dr. Hamza Mohammad Abdulghani MBBS, DPHC, ABFM, MRCGP (UK). December 1, 2007. 3. Nancy Schimelpfening. Difference between Male and Female Depression Symptoms, Health's Disease and Condition. September 01, 2011. 4. Adolescent Depression and Suicide: Early Detection and Treatment the Key http://www.termpaperadvisor.com/Free%20Term%20Papers%20and%20E ssays/Psychology%20Term%20Papers/Adolescent%20Depression%20And% 20Suicide%20Early%20Detection%20And%20Treat.htm 5. Lawrence Mundia, The prevalence of depression, anxiety and stress in Brunei. Journal of Applied Research in Education, 2008, Vol 12, 111-125 6. Escobedo, Reddy, & Giovino, 1998; Kessler, Berglund, Foster, Saunders, Stang, & Walters, 1997; Lewinsohn, Clarke, Seeley, & Rhode, 1994; Petersen, Compas, Brooks-Gunn, Stemmler, Ey, & Grant, 1993. 7. http://en.wikipedia.org/wiki/Major_Depression_Inventory 8. http://www.webmd.com/depression/guide/depression-types 9. http://www.monsteressays.com/search.cgi?query=depression 10.http://EzineArticles.com/?expert=Michael_Cooper (http://www.TermPaperAdvisor.com and http://www.TermPapersMadeEasy.com) 11.Roh, Myoung-Sun MD, PhD; Jeon, Hong Jin MD, PhD; Kim, Hana MA; Han, Sung Koo MD, PhD; Hahm, Bong-Jin MD, PhD. The Prevalence and Impact of Depression Among Medical Students: A Nationwide Cross-Sectional Study in South Korea. August 2010 - Volume 85 - Issue 8 - pp 1384-1390.

12.S .N. B. Inam, A. Saqib, E. Alam. Prevalence of Anxiety and Depression among Medical Students of Private University. 1990; 4:193-202. 17.

ANNEXES

Department of Community Medicine Khartoum College of Medical Sciences The prevalence of depression among medical students in Khartoum College of Medical Sciences at different levels of education, taking gender differences into account.

1. What is your gender? Male Female 2. Level of education? 1st Year 3rd Year 6th Year 3. Age in years? __________

[ [ [ [ [

] ] ] ] ]

The following questions ask about how you have been feeling over the past two weeks. Please put a tick in the box which is closest to how you have been feeling. How much of the time... 4. Have you felt low in spirits or sad? All the time Most of the time Slightly more than half the time Slightly less than half the time Some of the time At no time All the time Most of the time Slightly more than half the time Slightly less than half the time

5 4 3 2 1 0 5 4 3 2

5. Have you lost interest in your daily activities?

Some of the time At no time

1 0

6. Have you felt lacking in energy and strength? All the time Most of the time Slightly more than half the time Slightly less than half the time Some of the time At no time

5 4 3 2 1 0

7. Have you felt less self-confident? All the time Most of the time Slightly more than half the time Slightly less than half the time Some of the time At no time

5 4 3 2 1 0

8. Have you had a bad conscience or feelings of guilt? All the time Most of the time Slightly more than half the time Slightly less than half the time Some of the time At no time

5 4 3 2 1 0

9. Have you felt that life wasnt worth living? All the time Most of the time Slightly more than half the time Slightly less than half the time Some of the time

5 4 3 2 1

At no time

10. Have you had difficulty in concentrating, e.g. during class or when studying for an exam? All the time Most of the time Slightly more than half the time Slightly less than half the time Some of the time At no time

5 4 3 2 1 0

11. (a) Have you felt very restless? All the time Most of the time Slightly more than half the time Slightly less than half the time Some of the time At no time

5 4 3 2 1 0

(b) Have you felt subdued or slowed down? All the time Most of the time Slightly more than half the time Slightly less than half the time Some of the time At no time

5 4 3 2 1 0

12. Have you had trouble sleeping at night? All the time Most of the time Slightly more than half the time Slightly less than half the time Some of the time

5 4 3 2 1

At no time

13. (a) Have you suffered from reduced appetite? All the time Most of the time Slightly more than half the time Slightly less than half the time Some of the time At no time

5 4 3 2 1 0

(b) Have you suffered from increased appetite? All the time Most of the time Slightly more than half the time Slightly less than half the time Some of the time At no time

5 4 3 2 1 0

Total Score: