Supplementary Online Content

Mata DA, Ramos MA, Bansal N, et al. Prevalence of depression and depressive
symptoms among resident physicians: a systematic review and meta-analysis. JAMA.
doi:10.1001/jama.2015.15845.

eMethods 1. Search strategy used in the current systematic review and meta-analysis.

eMethods 2. Modified Newcastle-Ottawa scoring guide.

eTable 1. Newcastle-Ottawa risk of bias assessment.

eTable 2. Sensitivity analysis. Legend: Summary estimates were calculated omitting one

study at a time using a random effects model. Abbreviations: CI, confidence interval.

eTable 3. Within-instrument heterogeneity analyses.

eTable 4. Sensitivities and specificities of commonly used instruments for diagnosing

major depressive disorder.

eFigure. Assessment of small study effects by funnel plot and Egger test.

This supplementary material has been provided by the authors to give readers additional
information about their work.

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 eMethods 1. Search strategy used in the current systematic review and meta-analysis.

Depression 24. Resident physicians

1. Depressed 25. OR / 13 – 24
2. Depression
3. Depression [MeSH] Study design
4. Depressive disorder [MeSH] 26. Cohort stud*
5. Depressive disorder, major [MeSH] 27. Cohort studies [MeSH]
6. Major depression 28. Cross-sectional studies [MeSH]
7. Major depressive disorder 29. Epidemiologic stud*
8. MDD 30. Epidemiologic studies [MeSH]
9. Sadness 31. Incidence
10. Suicid* 32. Longitudinal stud*
11. Suicide [MeSH] 33. Meta-analy*
12. OR / 1 – 11 34. Meta-analysis [Publication Type]
35. Observational stud*
Interns and resident physicians 36. Population stud*
13. Education, medical [MeSH] 37. Prevalence
14. Education, medical, graduate 38. Prospective stud*
[MeSH] 39. Prospective studies [MeSH]
15. Fellow* 40. Retrospective stud*
16. House staff 41. Retrospective studies [MeSH]
17. Intern 42. Review [Publication Type]
18. Interns 43. Systematic review
19. Internship 44. OR / 26 – 43
20. Internship and residency [MeSH]
21. Medical resident Combined search
22. Medical residents 45. #12 AND #25 AND #44
23. Resident physician

Abbreviations: MeSH, Medical Subject Heading in MEDLINE.

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 eMethods 2. Modified Newcastle-Ottawa scoring guide.

(1) Representativeness of the sample:

1 point: Population contained a mixture of specialties at multiple sites.

0 points: Population contained a single specialty at a single site.

(2) Sample size:

1 point: Sample size was greater than 200 participants.

0 points: Sample size was less than 200 participants or a convenience sample.

(3) Non-respondents:

1 point: Comparability between respondent and non-respondent characteristics was

established, and the response rate was satisfactory.
0 points: The response rate was unsatisfactory, the comparability between respondents
and non-respondents was unsatisfactory, or there was no description of the response rate
or the characteristics of the responders and the non-responders.

(4) Ascertainment of depression:

1 point: Validated measurement tool using a validated cutoff score.

0 points: Non-validated measurement tool, or validated measurement tool with non-valid
cutoff score, or 2-item PRIME-MD (scored as such due to its low specificity).

(5) Quality of descriptive statistics reporting:

1 point: Reported descriptive statistics to describe the population (e.g., age, sex) with
proper measures of dispersion (e.g., standard deviation, standard error, range).
0 points: Descriptive statistics were not reported, were incomplete, or did not include
proper measures of dispersion.

Legend: This scale, the scoring of which ranges from 0 to 5, assesses quality in several domains:
sample representativeness and size, comparability between respondents and non-respondents,
ascertainment of depressive symptoms, and statistical quality. Studies were judged to be of low
risk of bias (≥3 points) or high risk of bias (<3 points).

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  eTable 1. Newcastle‐Ottawa Risk of Bias Assessment.   
   Representativeness  Size  Comparability  Outcome  Statistics  Total 
Cross‐sectional studies                   
1
   Waring EM, 1974   0  0  1  1  0  2 
   Valko RJ, 19752  1  0  0  1  0  2 
3
   Hsu K, 1987   1  1  0  1  1  4 
4
   Kirsling RA, 1989   1  0  1  1  0  3 
   Steinert Y, 19915  1  1  0  1  1  4 
6
   Godenick MT, 1995   1  0  0  1  1  3 
7
   Hainer BL, 1998   1  1  0  1  1  4 
8
   Raviola G, 2002   1  0  0  1  0  2 
   Shanafelt TD, 20029  0  0  0  0  0  0 
10
   Oriel K, 2004   1  0  0  0  0  1 
11
   Earle L, 2005   1  1  0  1  1  4 
12
   Becker JL, 2006   1  0  0  1  1  3 
   Cruz EP, 200613  1  0  0  0  0  1 
14
   Yi MS, 2006   1  1  0  0  1  3 
15
   Demir F, 2007   1  0  0  1  1  3 
   Hasanovic M, 200816  1  0  0  1  1  3 
17
   Sakata Y, 2008   1  0  0  1  1  3 
18
   Sánchez MJB, 2008   1  0  1  1  1  4 
19
   Goebert D, 2009   1  1  0  1  0  3 
   Waldman SV, 200920  1  0  0  1  1  3 
21
   Lam TP, 2010   1  0  0  1  1  3 
22
   Hsieh YH, 2011   1  1  0  0  0  2 
23
   Yousuf A, 2011   1  0  0  0  1  2 
   Costa EF, 201224  0  0  1  1  1  3 
25
   Govardhan LM, 2012   1  0  0  1  1  3 
26
   de Oliviera, 2013   1  1  1  1  1  5 
   Al Ghafri G, 201427  1  0  0  1  1  3 
28
   Dyrbye LN, 2014   1  1  0  0  1  3 
29
   Stoesser K, 2014   1  1  0  1  1  4 
30
   Al‐Maddah EM, 2015   1  0  0  1  1  3 
   Pereira‐Lima K, 201531  1  1  0  1  1  4 
Longitudinal studies                   
32
   Ford CV, 1984   1  0  1  1  0  3 
   Reuben DB, 198533  0  0  0  1  0  1 
34
   Revicki DA, 1993   1  1  0  1  1  4 
35
   Gopal R, 2005   0  0  1  0  1  2 
36
   Katz ED, 2006   1  0  1  0  1  3 
   Rosen IM, 200637  0  0  1  1  0  2 
38
   West CP, 2006   0  0  1  0  1  2 
39
   Wada K, 2007   1  0  1  1  1  4 

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  eTable 1. Newcastle‐Ottawa Risk of Bias Assessment.   
   Representativeness  Size  Comparability  Outcome  Statistics  Total 
40
   Fahrenkopf AM, 2008   1  0  1  1  1  4 
41
   Landrigan CP, 2008   1  1  0  1  1  4 
   Buddeberg‐Fischer B, 200942  1  1  0  0  1  3 
43
   West CP, 2009   0  1  1  0  1  3 
44
   Campbell J, 2010   0  0  0  0  1  1 
   Sen S, 201045  1  1  1  1  1  5 
46
   Beckman TJ, 2012   0  1  1  0  1  3 
47
   Weigl M, 2012   1  1  0  1  1  4 
48
   West CP, 2012   0  1  1  0  1  3 
   Sen S, 201349  1  1  1  1  1  5 
50
   Velásquez‐Pérez L, 2013   1  0  0  1  1  3 
51
   Kleim B, 2014   1  0  0  0  1  2 
52
   Cubero DI, 2015   1  0  0  1  1  3 
   Ito M, 201553  1  1  0  1  1  4 
54
   Jiménez‐López JL, 2015   1  0  0  0  1  2 

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 eTable 2. Sensitivity Analysis.                
Lower 95%  Upper 95%  2 2
First Author, Year  Prevalence (%)  tau   I 
CI  CI 
Omitting Weigl M, 201247  29.2  25.7  32.9  0.38  95.7% 
Omitting Jiménez‐López JL, 201554  28.9  25.4  32.6  0.39  95.8% 
Omitting Rosen IM, 200637  28.8  25.3  32.5  0.39  95.8% 
Omitting Godenick MT, 19956  29.3  25.8  33.0  0.38  95.7% 
Omitting Hainer BL, 199855  29.3  25.8  33.0  0.38  95.7% 
Omitting Kirsling RA, 19894  29.0  25.5  32.8  0.39  95.8% 
Omitting Velásquez‐Pérez L, 
28.8  25.3  32.6  0.39  95.8% 
201350 
Omitting Costa EF, 201224  28.6  25.1  32.3  0.39  95.8% 
Omitting Waldman SV, 200920  28.5  25.0  32.2  0.39  95.8% 
Omitting Al‐Maddah EM, 201530  28.2  24.8  31.8  0.37  95.5% 
Omitting Demir F, 200715  28.7  25.2  32.5  0.39  95.8% 
Omitting Cubero DI, 201552  28.7  25.2  32.5  0.39  95.8% 
Omitting West CP, 200638  28.7  25.2  32.5  0.39  95.8% 
Omitting Beckman TJ, 201246  28.7  25.1  32.4  0.39  95.8% 
Omitting West CP, 200943  28.6  25.1  32.4  0.39  95.8% 
Omitting West CP, 201248  28.5  25.0  32.3  0.39  95.7% 
Omitting Shanafelt TD, 20029  28.5  25.0  32.2  0.39  95.8% 
Omitting Dyrbye LN, 201428  28.4  25.3  31.8  0.30  93.9% 
Omitting Gopal R, 200535  28.4  24.9  32.1  0.38  95.7% 
Omitting Campbell J, 201044  28.4  24.9  32.1  0.38  95.8% 
Omitting Oriel K, 200410  28.7  25.2  32.5  0.39  95.8% 
Omitting Katz ED, 200636  29.0  25.5  32.8  0.39  95.8% 
Omitting Revicki DA, 199334  28.8  25.3  32.7  0.41  95.8% 
Omitting Govardhan LM, 201225  28.6  25.1  32.4  0.39  95.8% 
Omitting Yi MS, 200614  28.8  25.3  32.6  0.39  95.8% 
Omitting Goebert D, 200919  29.2  25.8  33.0  0.37  95.6% 
Omitting Reuben DB, 198533  28.9  25.4  32.7  0.39  95.8% 
Omitting Hsu K, 19873  28.9  25.3  32.8  0.41  95.7% 
Omitting Becker JL, 200612  28.7  25.2  32.4  0.39  95.8% 
Omitting Ito M, 201553  28.6  25.0  32.5  0.42  95.8% 
Omitting Sakata Y, 200817  28.8  25.3  32.6  0.39  95.8% 
Omitting Wada K, 200739  28.6  25.1  32.4  0.39  95.8% 
Omitting Lam TP, 201021  28.4  25.0  32.2  0.39  95.8% 
Omitting Waring EM, 19741  28.9  25.4  32.7  0.39  95.8% 
Omitting Buddeberg‐Fischer B, 
29.1  25.6  32.9  0.38  95.7% 
200942 
Omitting Sánchez MJB, 200818  28.5  25.0  32.3  0.39  95.8% 
Omitting Landrigan CP, 200841  29.0  25.5  32.8  0.39  95.8% 
Omitting de Oliviera, 201326  28.9  25.4  32.8  0.40  95.7% 
Omitting Fahrenkopf AM, 200840  29.0  25.5  32.8  0.39  95.8% 
Omitting Hasanovic M, 200816  28.9  25.4  32.7  0.39  95.8% 

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 eTable 2. Sensitivity Analysis.                
Lower 95%  Upper 95%  2 2
First Author, Year  Prevalence (%)  tau   I 
CI  CI 
Omitting Pereira‐Lima K, 201531  28.9  25.4  32.7  0.39  95.8% 
Omitting Stoesser K, 201429  29.0  25.5  32.8  0.39  95.8% 
Omitting Sen S, 201349  29.0  25.5  32.8  0.39  95.4% 
Omitting Earle L, 200511  29.0  25.4  32.8  0.39  95.8% 
Omitting Sen S, 201045  28.8  25.3  32.7  0.40  95.8% 
Omitting Al Ghafri G, 201427  29.2  25.7  33.0  0.38  95.8% 
Omitting Kleim B, 201451  28.6  25.1  32.3  0.39  95.8% 
Omitting Valko RJ, 19752  28.7  25.3  32.5  0.39  95.8% 
Omitting Ford CV, 198432  29.0  25.5  32.7  0.39  95.8% 
Omitting Raviola G, 20028  28.5  25.0  32.2  0.39  95.8% 
Omitting Cruz EP, 200613  29.0  25.5  32.8  0.39  95.8% 
Omitting Hsieh YH, 201122  28.4  25.0  32.1  0.38  95.7% 
Omitting Yousuf A, 201123  28.3  24.9  31.9  0.37  95.6% 
Omitting Steinert Y, 19915  28.8  25.3  32.6  0.39  95.8% 
Pooled estimate  28.8  25.3  32.5  0.39  95.8% 

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 eTable 3. Within‐instrument heterogeneity analyses.                      
Stratified Meta‐Analyses                            
No. 
PRIME‐MD  Prevalence LCI UCI Q  tau2  I2 P for diff. Q
Studies
   Cohort  6 41.3% 35.4% 47.5% 19.8  0.1  74.8% 0.02 5.2
   Cross‐sectional  2 49.8% 46.0% 53.6% 1.3  0.0  20.2%    
                         
   Comparable respondents  5 39.6% 33.8% 45.7% 14.7  0.1  72.7% 0.00 10.3
   Non‐comparable  3 50.4% 48.1% 52.6% 1.4  0.0  0.0%    
                         
   Size ≥200  4 41.9% 34.1% 50.1% 30.9  0.1  90.3% 0.64 0.2
   Size <200  4 44.9% 35.5% 54.6% 13.2  0.1  77.3%    
                         
   NCOS ≥3  4 41.9% 34.1% 50.1% 30.9  0.1  90.3% 0.64 0.2
   NCOS <3  4 44.9% 35.5% 54.6% 13.2  0.1  77.3%    
                         
CES‐D, ≥16                     
   Cohort  3 27.9% 20.2% 37.2% 32.4  0.1  93.8% 0.61 0.3
   Cross‐sectional  4 24.4% 15.7% 35.9% 48.7  0.3  93.8%    
                         
   Non‐surgical  2 24.7% 22.3% 27.2% 0.3  0.0  0.0% 0.70 0.2
   Non‐surgical and surgical  5 26.5% 18.3% 36.9% 120.9  0.3  96.7%    
                         
   Size <200  3 31.4% 23.4% 40.6% 4.1  0.1  50.7% 0.15 2.1
   Size ≥200  4 22.8% 16.0% 31.3% 115.3  0.2  97.4%    
                         
BDI, ≥10                     
   Non‐USA  4 44.6% 30.5% 59.6% 24.5  0.3  87.8% < .0001 30.7
   USA  3 10.7% 8.3% 13.8% 1.7  0.0  0.0%    
                         
   Non‐surgical  4 22.6% 8.8% 47.0% 81.0  1.2  96.3% 0.58 0.3
   Non‐surgical and surgical  3 32.9% 9.9% 68.4% 42.7  1.6  95.3%    

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 eTable 3. Within‐instrument heterogeneity analyses.                      
Stratified Meta‐Analyses                            
No. 
PRIME‐MD  Prevalence LCI UCI Q  tau2  I2 P for diff. Q
Studies
                         
Both interns and upper 
   4 26.9% 8.3% 60.1% 156.1  2.0  98.1% 0.99 0.0
levels 
   Only interns  3 26.7% 14.2% 44.4% 10.1  0.4  80.3%    
                         
   Comparable respondents  2 26.7% 9.2% 56.8% 9.5  0.8  89.4% 1.00 0.0
   Non‐comparable  5 26.7% 9.9% 54.6% 157.5  1.8  97.5%    
                         
Meta‐regression Analyses                     
PRIME‐MD  Slope SE Z P LCI  UCI    P (mod) Q (mod)
   Percent males  ‐0.6 0.4 ‐1.6 0.1 ‐1.4  0.1    0.10 2.7
   Baseline year  0.0 0.0 0.2 0.8 0.0  0.0    0.80 0.1
   Average age  ‐ ‐ ‐ ‐ ‐  ‐    ‐ ‐
                         
CES‐D                     
   Percent males  ‐0.1 0.2 ‐0.8 0.4 ‐0.5  0.2    0.41 0.7
   Baseline year  0.0 0.0 1.2 0.2 0.0  0.0    0.25 1.3
   Average age  0.0 0.0 ‐0.8 0.4 ‐0.1  0.0    0.41 0.7
                         
BDI                     
   Percent males  ‐1.6 0.5 ‐3.3 0.0 ‐2.5  ‐0.6    0.00 10.7
   Baseline year  0.0 0.0 3.7 0.0 0.0  0.0    0.00 13.4
   Average age  0.0 0.0 ‐1.1 0.3 ‐0.1  0.0    0.26 1.3

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 eTable 4. Sensitivities and Specificities of Commonly Used Instruments for 
Diagnosing Major Depressive Disorder. 
Instrument  Cutoff  Sensitivity Specificity
21‐item BDI  ≥10  91 (86 to 96) 79 (52 to 100)
2‐item PRIME‐MD  Yes to either  91 (81 to 100) 66 (48 to 84)
CES‐D  ≥16  84 (79 to 89) 74 (68 to 80)
CES‐D  ≥19  93 (NR) 92 (NR)
GHQ  ≥4  86 (76 to 95) 66 (57 to 74)
HADS‐D  ≥11  69 (45 to 86) 86 (73 to 93)
HANDS  ≥9  95 (NR) 94 (NR)
HSCL  ≥43  82 (71 to 93) 73 (52 to 94)
PHQ‐9  ≥10  88 (74 to 96) 88 (85 to 90)
Zung SDS  ≥50  86 (73 to 100) 76 (57 to 95)

Legend: Sensitivities and specificities as reported by Williams et al.56

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 eFigure. Assessment of small study effects by funnel plot and Egger test.

0.0
0.1
0.2
Standard error

0.3
0.4
0.5

-2.0 -1.5 -1.0 -0.5 0.0 0.5

Logit Transformed Proportion

Legend: The linear regression test of funnel plot asymmetry suggested the presence of

publication bias (P = .02).

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