Depression and stress among the first year medical students in university of medicine and pharmacy at hochiminh city, vietnam

CHAPTER 1 INTRODUCTION 1.1 Rationale and justification of the study Oral diseases, such as dental caries and periodontal diseases are most common chronic infectious diseases. Most caries and periodontal diseases are preventable, as recommended by resolution WHA 53.17 of the Fiftythird World Health Assembly in 2000 (1). However, the consequences of oral diseases are not only affected to oral cavity, but also to other systemic diseases such as diabetes, cardiovascular diseases, or respiratory diseases, preterm and low birth weight (2). There are several bacterial strains in normal flora of the oral cavity. Most of them are pathogens. Bacteria exist mainly inside the dental plaque and dental calculus and on the surface of soft tissue. Dental plaque was formed from mixture of food, saliva and other organic compounds inside oral cavity and it is the main cause of oral

DEPRESSION AND STRESS AMONG THE FIRST YEAR MEDICAL STUDENTS IN UNVERSITY OF MEDICINE AND PHARMACY

HOCHIMINH CITY, VIETNAM

Ms Quyen Dinh Do

A Thesis Submitted in Partial fulfillment of the Requirements

for the Degree of Master of Public Health Program in Health Systems Development

College of Public Health Sciences, Chulalongkorn University Academic Year 2007 Copyright of Chulalongkorn University

Thesis Title DEPRESSION AND STRESS AMONG THE FIRST YEAR

MEDICAL STUDENTS IN UNIVERSITY OF MEDICINE AND PHARMACY AT HOCHIMINH CITY, VIETNAM

Field of Study Health Systems Development

Thesis Advisor Associate Professor Prida Tasanapradit, M.D., M.Sc

Accepted by The College of Public Health Sciences, Chulalongkorn University,

in Partial Fulfillment of the Requirement for the Master’s Degree

……….……… Dean of College of Public Health Sciences (Professor Surasak Taneepanichsakul, M.D.)

PH: 072464 : MAJOR HEALTH SYSTEMS DEVELOPMENT

KEY WORDS : CES-D/ DEPRESSION/ MEDICAL STUDENT STRESS

QUYEN DINH DO: DEPRESSION AND STRESS AMONG THE FIRST YEAR MEDICAL STUDENTS IN UNIVERSITY OF MEDICINE AND

ASSOCIATE PROFESSOR PRIDA TASANAPRADIT M.D., 95 pp

Objectives: 1) to assess the prevalence of depression by using the Center for

Epidemiologic studies depression scale (CES-D) 2) to determine sources of stress 3)

to find out the relationship between the main sources of stress, the general characteristics, potential personal consequences and depression among the first year Medical students in February, 2008

Methods: in cross-sectional descriptive study design, CES-D with cut-off

point 22 and Students Stress Survey questions were used as self-administrated to 351 first year Medical students in Hochiminh city Chi-squared test, Spearman correlation were analyzed in bivariate analysis, binary Logistic regression used in multivariate analysis

Results: the prevalence of depression was 39.6% The top five of stress was

prone intrapersonal factors, academic environment and environmental factors Stress scores and depression scores had positive linear relationship with r = 0.272 There were significant different between depressive symptom group and ethnicity, type of accommodation, whom the students living with, exercise practice, perception of financial status, satisfaction of relationship with parents and friends Working with un-acquainted people, decline in personal health, increased class workload, and put on hold for extended period of time as stressors were differentiated significantly with depressive group Among those variables, quality of relationship, and stressors as decline in personal health, fight with friend and put on hold for long time increased the risk to get depression; in contrast, living with family, practice exercise, working with un-acquainted people reduced the risk of depression with p-value<0.05 in multivariate analysis

For further study, qualitative and quantitative as longitudinal study should be conducted to determine consequences of daily hassles, level of stress and its relationship with depression in duration of Medical learning as well as in different faculty for a broader picture about depression in Medical University in Vietnam

Field of Study Heath Systems Development Student’s signature

ACKNOWLEDGEMENTS

I would like to express my deep appreciation to Associate Professor Prida Tasanapradit, my thesis advisor, for his guidance and supervision throughout this study His invaluable advices have motivated me on doing research

Most importantly, I am very grateful to Dr Ratana Somrongthong, for her encouragement and valuable suggestions that I was able to accomplish my study

I also would like to thank my committee members: Dr Prathurng Hongsranagon, my Chairman and Dr Rasmon Kalayasiri, my external thesis examiner, for providing me valuable suggestions and comments on my proposal and thesis as well

Special appreciations are extended to Dr Robert Sedgwick Chapman, Arj Piyalamporn Havanont and Arj Venus Udomprasertgul, for their teaching, providing valuable knowledge and advice about Statistics and Epidemiology My sincere gratefulness goes to all my teachers and staff of the College of Public Health

Sciences, Chulalongkorn University for, their kindness and support for my study

Most of all, the deepest gratitude goes to my family for their love and care which have been a tremendous encouragement to me in my study I also want to thank

my friends, classmates, for being my friends and supporting me in their kindly and friendly way

Last but not the least; I am grateful to Thailand International Cooperation Agency – Colombo Plan scholarship for my study grant

TABLE OF CONTENTS

Page

ABSTRACT. …… … ………i

ACKNOWLEDGEMENTS ………… ………ii

TABLE OF CONTENT. ……… ……… v

LIST OF TABLES.. ……… ……… viii

LIST OF FIGURES ……… ………x

ABBREVIATIONS. ……… ……… xi

CHAPTER I INTRODUCTION. ……….1

1.1 Background 1

1.2 Research questions 3

1.3 Study hypotheses 3

1.4 Objectives ………3

1.4.1 General objectives 3

1.4.2 Specific objectives 4

1.5 Variables in this study 4

1.6 Operational definition 5

1.7 Conceptual framework 8

CHAPTER II LITERATURE REVIEW……… 9

2.1 Stress and Students Stress survey questions 9

2.2 Depression and CES-D 11

2.3 Review of related studies 14

2.4 Site of study 22

Page

CHAPTER III METHODOLOGY ………24

3.1 Research design 24

3.2 Study population 24

3.3 Sample size 24

3.4 Sampling technique 25

3.4.1 Inclusion criteria 25

3.4.2 Exclusion criteria 25

3.5 Data collection tool 25

3.6 Data collection procedure 26

3.7 Data analysis 26

3.8 Reliability and Validity 28

3.9 Ethical consideration 29

CHAPTER IV RESULTS.………….………30

4.1 Description of General characteristics 30

4.2 Potential personal consequence factors 35

4 3 Student stress factors 38

4 4 Prevalence of depression 42

4.5 Relationship between depression and related factors 42

4.5.1 Relationship between depression and general characteristics 43

4.5.2 Relationship between depression and potential personal consequence 47

4.5.3 Relationship between depression and student stress 50

Page

CHAPTER V DISCUSSION, CONCLUSIONS AND

RECOMMENDATIONS……… 63

5.1 Discussion 63

5.2 Conclusions 70

5.3 Recommendations 72

REFERENCES ……… 74

APPENDICES ………….……… 79

APPENDIX A: The relationship between depression and related factors … 80

APPENDIX B: CES-D Reliability Statistics ……… 81

APPENDIX C: Questionnaire (English version) ………82

APPENDIX D: Questionnaire (Vietnamese version) ……….87

APPENDIX E: Schedule Activities ………93

APPENDIX F: Administration Cost ……… 94

CIRRICULUM VITAE ………95

LIST OF TABLE

Page

Table 1: University of Medicine and Pharmacy 23

Table 2: Variables, measurement scale and statistic inference 28

Table 3: Description of general characteristics 32

Table 4: The student's religion and their religious practice 33

Table 5: Financial status 34

Table 6: Coping with problems 35

Table 7: Quality of friendship 36

Table 8: Quality of relationship with parents 37

Table 9: Leisure activities and exercise practice 38

Table 10: Student stress factors 40

Table 11: Prevalence of depression among the first year Medical students 42

Table 12: The relationship between depression and general characteristics 45

Table 13: The relationship between depression and religion practice 46

Table 14: The relationship between depression and perception of financial status 46

Table 15: The relationship between depression and coping with problems 47

Table 16: The relationship between depression and quality of relationship 48

Table 17: The satisfaction with friendship among students who have no close friend and lower 48

Table 18: The relationship between depression and exercise practice 49

Table 19: The relationship between leisure activities and depression 50

Table 20: The relationship between stress and depression 50

Page

Table 21: The relationship between depression and interpersonal sources 52

Table 22: The relationship between depression and intrapersonal sources 53

Table 23: The relationship between depression and academic sources 56

Table 24: The relationship between depression and environmental stress factors 58

Table 25: The relationship between depression and related factors in Logistic regression model 61

LIST OF FIGURES

Page Figure 1: Conceptual framework 8 Figure 2: Proposed model of causes and consequences of student distress 18

to 25% of the population in member countries region, in which, 15 to 20% children and adolescents suffered from it that are almost similar to that of adult populations (The World Health Organization [WHO]-Regional Office for South-East Asia, 2001).Inability to cope with intense emotions in healthy ways may lead adolescents to express their pain and frustration through violence or self-injury, or to attempt to numb themselves of emotions through isolation, reckless behaviors, and alcohol or illicit drug use Furthermore, other behaviors and attitudes are also linked to adolescent mental health: aggressiveness and disregard for laws or the rights of others; isolation from peers, family, and other emotional relationships; or the inability

to keep one's disappointments in perspective and academic stress

Medical university is responsible for ensuring that graduates are knowledgeable, skillful, and professional (Liaison Committee on Medical Education [LCME], 2003) Since the field of medical knowledge is immense and particularly science in training programs for specialist medical undergraduate and its education is

characterized by many psychological changes in students Many studies have explored high prevalence of psychological morbidity in medical students at different stage of their training (Aktekin et al., 2001) Unfortunately, some aspects of the training process have unintended negative consequences on students' personal health

It may, in fact, produce stress at levels which are hazardous to the physical and psychological wellbeing of students Although a moderate degree of stress can promote student creativity and achievement, the intense pressures and relentless demands of medical education may impair students' behavior, diminish learning, destroy personal relationships, and ultimately, affect patient care In addition, according to study of Marie Dahlin, Medical students are more distressed than the general population, especially in freshmen that face transitional nature of university life (Dahlin et al., 2005; Seyedfatemi et al., 2007)

In Vietnam, a national community-based study in 2005 of 5,584 young people aged 14-25 years found that a quarter report feeling so sad or helpless that they could

no longer engage in their normal activities and they found it difficult to function (Ministry of Health [MOH]-Vietnam, 2005) Somehow, there is a few published evidence and concern to solve the burden of mental health problem In medical university, it has also no study about stress, depression among students who will become future doctors with responsibility and capacity for caring health's community

University of Medicine and Pharmacy at Hochiminh city, the biggest city of the South Vietnam, is the main university educating the health professions for the South region This study wanted to explore what are the main sources of medical stress, screen the level of depression, and find their relationship between depression

and the main source of stress among the first year students by using the student stress survey tool and the Center for Epidemiologic Studies’ Depression Scales tool The finding would be a significant evidence to prevent mental disorder and improve the qualitative of education for this university as well

1.2 Research questions

− What is the prevalence of depression among the first year Medical students?

− What are the sources of stress among the first year Medical students?

− Is there any relationship between sources of stress, potential consequence factors and depression among the first year Medical students in University of Medicine and Pharmacy, Hochiminh city, 2008?

1.3 Study hypotheses

− There is a relationship between depression and sources of stress (interpersonal, intrapersonal, academic and environmental sources)

− There is a relationship between depression and individual characteristics

− There is a relationship between depression and potential personal consequences

1.4 Objectives

1.4.1 General objectives

The general objectives of this study are to measure the prevalence of depression; to determine the sources of stress; and the factors related to depression among the first students in University of Medicine and Pharmacy, Hochiminh city,

2008

1.5 Variables in this study

Background variables (general characteristics)

− Gender

− Age

− Ethnicity

− Living status

− Perception of financial status

− Coping with problem

Independent variables

Potential personal consequences

− Parents' marital status

− Quality of relationship with parents and friends

− Leisure activity

− Exercise practice

Student stress

− Interpersonal factors

Depression: in this study, adolescent depression is a disorder occurring during

the teenage years marked by persistent sadness, discouragement, loss of self-worth, and loss of interest in usual activities (Voorhees, 2007) The Center for Epidemiologic studies Depression scale (Radloff, 1991) will be used to measure depression

An overall CES-D score, the scores on the twenty above questions were combined The minimum and maximum score are 0 and 60, range from 0 to 60 With cut – off point 22, the following classification is defined for depressions

• Scores less than 22 = Non- depressive symptoms group

• Scores are 22 or more = Depressive symptoms group

CES-D emphasis on affective components: depressed mood, feelings of guilt,

worthlessness, feelings of helplessness and hopelessness, psychomotor retardation, loss of appetite, and sleep disorders CES-D question composed four factors:

• Depressed affect: blues, depressed, lonely, cry, sad

• Positive affect: good, hopeful, happy, enjoy

• Interpersonal affect: unfriendly, dislike

• Somatic and retarded activity: bothered, appetite, effort, sleep, going

The Student Stress was measured by students stress survey questionnaires

The questionnaire concludes 40 items divided 4 categories of potential sources of stress Respondents will be provided a “Yes” or “No” answer to each item for experience students had during the academic year (since September, 2007 to February, 2008)

• Interpersonal sources: 6 items

• Intrapersonal sources: 16 items

• Academic sources: 8 items

• Environmental sources: 10 items

Age is a continuous variable

Gender is a nominal variable with female and male values

Ethnicity is nominal variable with 5 values: Vietnamese, Hoa (Chinese),

Khmer, Chăm and other

Living status compose 4 nominal variables with following values:

• Hometown: HoChiMinh and Non- HoChiMinh

• Living location: Inner city and Suburban district

• Type of accommodation: Dormitory, Rented room/house and Own

home, Relative's home and others

• Whom students lived with: Alone, Friend, Relative, and Family

Perception of financial status is an ordinal variable about students' feeling on

their financial status using Likert scale with values: not enough for tuition fee, not enough for living spending, nearly sufficient, sufficient, and comfortable

Living spending referred for spending on shopping or for rent a good quality room/house, allowance, etc, excluding money for food

Practice of religion is an ordinal variable about participation in religious

services and activities as going to church or pagoda or fasting and following other religious regulations, by using Likert scale with values: rarely, sometime (≥ twice/year & < once/4 week), often (≥ one/4 week & < one/week) and always (≥ once/week)

Coping with problem is a nominal variable about the way student coping

with problems including talking with parents, talking with friends, solving by yourself, praying, smoking/drinking, and others

Potential personal consequences

Parents' marital status is a nominal variable about marital status of parents'

students including live together, separated, divorce and parental loss

Exercise practice is an ordinal variable about regularity in exercise practice

using Likert scales as never, seldom (< 1 time/month), sometime (≥ 1 & ≤ 3 times/month), often (> 3 & < 12 times/month), and always (≥ 12 times/moth)

Leisure activity is a nominal variable about activities that students often do in

their free time with values such as going out with friends, listening to music/reading book/watching TV/playing game, playing sport, sleeping, others

Quality of relationship with friends and parents are an ordinal variable

reflecting through satisfaction of students about their relationship with parents and friends by Likert scales: very satisfy, satisfy, not satisfy and not satisfy at all

1.7 Conceptual framework

The outcome variable is prevalence of depression that related to general characteristics, potential personal consequences and student stress General characteristics conclude age, gender, ethnicity, living status, practice of religion, perception of financial status and coping with problems The potential personal consequences consist of parents' marital status, quality of relationship, and leisure/excise activity These factors change differently and influence on prevalence depression in medical students

Figure 1: Conceptual framework

Independent variables Dependent variable

Perception of financial status

Coping with problem

Potential personal consequences

Parents' marital status

Quality of relationship

Leisure/Exercise activity

CHAPTER II

LITERATURE REVIEW

In this part, the knowledge about stress, depression, and related factors had been reviewed to introduce an overview about mental status of student in Medical University Several previous studies in this field also had been reviewed and were used as references

2.1 Stress and Students Stress survey questions

Stress

Stress is a term that refers to the sum of the physical, mental, and emotional strains or tensions on a person Feelings of stress in humans result from interactions between persons and their environment that are perceived as straining or exceeding their adaptive capacities and threatening their well-being The element of perception indicated that human stress responses reflect differences in personality as well as differences in physical strength or health

A stressor is defined as a stimulus or event that provokes a stress response in

an organism Stressors can be categorized as acute or chronic, and as external or internal to the organism The Diagnostic and Statistical Manual of Mental Disorders (DAM-IV-TR) defines a psychosocial stressor as "any life event or life change that may be associated temporally (and perhaps causally) with the onset, occurrence, or exacerbation (worsening) of a mental disorder" Stress is also closely associated with depression and can worsen the symptoms of most other disorders (Rebecca, 2003)

Richard Lazarus published in 1974 a model dividing stress into eustress and distress Where stress enhances function (physical or mental, such as through strength training or challenging work) it may be considered eustress Persistent stress that is not resolved through coping or adaptation, deemed distress, may lead to escape (anxiety) or withdrawal (depression) behavior The difference between experiences which result in eustress or distress is determined by the disparity between an experience (real or imagined), personal expectations, and resources to cope with the stress Alarming experiences, either real or imagined, can trigger a stress response (Lazarus, 1993)

As "Beyond blue: the national depression initiative" approach that aims to

influence broader social determinants, the settings in which people spend their time, there are some causes of depression need an attention on the peak incidence in mid-to-late adolescence:

Cumulative adverse experiences, including negative life events and early childhood adversity, together with parental depression and/or non-supportive school

of familial environments, place young people at risk for developing depression Enhanced life skills and supportive school and family environments can mediate the effect of stressful life events

Obviously, school is an important arena for social and emotional development; however, it can also be a source of negative life events Poor academic achievement and beliefs about academic ability, coupled with depression, result in poor school engagement, enhanced perceptions of school-related stress, and increased problem

behaviors (Burns et al., 2002)

The Student Stress Survey

The Student Stress Survey (Insel et al., 1985) will be used to measure sources

of stressors This survey consists of 40 items divided into 4 categories of potential sources of stress: 6 items representing interpersonal sources of stress, 16 representing intrapersonal sources of stress, 8 representing academic sources of stress, and

10 representing environmental sources of stress Interpersonal sources result from interactions with other people, such as a fight with a boyfriend or girlfriend or trouble with parents; intrapersonal sources result from internal sources, such as changes in eating or sleeping habits Academic sources arise from school-related activities and issues, such as increased class workload or transferring between schools Environmental sources result from problems in the environment outside of academics, such as car or computer problems and crowded traffic Respondents provided a “Yes” or “No” answer to each item they had experienced during the current school year (Seyedfatemi et al., 2007)

2.2 Depression and CES-D

Depression is a common mental disorder that presents with depressed mood, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy, and poor concentration These problems can become chronic or recurrent and lead to substantial impairments in an individual's ability to take care of his or her everyday responsibilities (WHO, 2008)

According to WHO's Global burden of disease 2001, 33% of the years lived with disability (YLD) are due to neuropsychiatry disorders in which including depression is one of four neuropsychiatry disorders of the six leading to causes of

years lived with disability More than 150 million persons suffer from depression at any point in time (WHO, 2003)

Depending on the nature and severity of symptoms, the depressive episode may be classified as mild, moderate and severe, or with psychotic features About 15% of severely depressed cases suffer from what is termed as the 'psychotic form' of depression where they have symptoms which signify their being out of touch with reality They have delusions (false fixed ideas not amenable to correction) and hallucinations (perceiving something through sense organs without anything being there)

Depression is a complex disorder which can manifest itself under a variety of circumstances and due to a multiplicity of factors The bio-psychosocial model is useful to understand the causation of depression including:

• Biological (genetic and biochemical)

• Sociological (stressors)

• Psychological (development and life experiences)

The following are various risk factors of depression in adolescent (The World Health Organization [WHO]-Regional Office for South-East Asia, 2001):

• Marital status

• Family history

• Parental deprivation: Parental loss

• Social stressors: life events, chronic stress, and daily hassles

• Social support

• Family type

Depression measurement

According to Ian McDowell in Measuring health book, depression measurements are divided into two major groups self-rating methods and clinician-rating scales, which correspond roughly to their use in clinical versus epidemiological studies A formal diagnosis of depression requires the exclusion of other explanations for the symptoms, and this requires a clinical examination However, self-assessed measures of depression that is popular and easy to administer, can identify the syndrome of depression but, as with dementia, cannot be regarded as diagnostic devices This book introduced nine self-rating that have been widely used and tested Among several methods, the Center for Epidemiologic studies Depression Scale is a depression screening instruments designed for adolescent survey use (McDowell, 2006)

CES-D questionnaire

This study adopted the Center for Epidemiologic Studies’ Depression Scales (CES-D) to measure the levels of adolescent depression The CES-D was designed to cover the major symptoms of depression identified in the literature, with an emphasis

on affective components: depressed mood, feelings of guilt and worthlessness, feelings of helplessness and hopelessness, psychomotor retardation, loss of appetite, and sleeping disorders It composes of 20 questions asking about adolescents’ feelings or behaviors related to depressive symptoms It has been extensively used in large studies and norms are available It is applicable across age and general groups It has often been used in cross-cultural research (Iwata et al., 2002; McDowell, 2006)

Items in CES-D were selected from many other scales as Beck’s depression inventory (BDI), Zung’s self-rating depression scale, Raskin’s depression scale, and the Minnesota Multiphasic personality inventory It performs comparably with other self-report scales and CES-D is better than BDI’s where there is a relatively high prevalence of depression (McDowell, 2006)

Moreover, this instrument used for Thai adolescents which its results show the Cronbach alpha coefficient of the CES-D was 0.86, that the validity was significant with Mean = 25.6, SD = 8.8, compared with non-depressed subjects with Mean = 15.4, SD = 6.7, that the sensitivity was 72%, the specificity was 85% and the accuracy was 82%; the cutting point = 22 scores The report shown that the sample was diagnosed for depression at the significant p-value < 0.001 (Trangkasombat et al., 1997)

2.3 Review of related studies

Studies used CES-D

In adolescent depression and risk factors study by Tiffany, seventy nine high school seniors from suburban Florida were administered the CES-D as well as a questionnaire of parent/peer relationships, suicidal thoughts, academic performance, exercise, and drug use The extremely high incidence of adolescents who scored above the cut-off >19 for depressed mood (37%) had poorer relations with parents The depressed adolescents also had less optimal peer relationships, fewer friends, less popular, less happiness, and more frequents suicidal thoughts They spent less time doing homework, had a lower grade point average, and less time exercising (Field et al., 2001)

A study in Thai done by Ratana in 2003, she measured depressive prevalence

by using CES-D (with cut-off point 22) in 871 adolescents aged 12-22 years One third (34.9%) of the subjects having depressive symptoms, late adolescents (18-22 years) suffered with high percentage at 33.1%, gender differences existed in depressive symptoms in all subjects with p-value < 0.001, female were more likely than males to have depressive symptoms (Somrongthong, 2004)

The Black women's health study in 35,224 women ages 21 to 69 in African American measured depressive symptoms in which CES-D was used and its association with physical activity Adult vigorous physical activity was inversely associated with depressive symptoms Women who reported vigorous exercise both in high school (≥ 5 hr per week) and adulthood (≥ 2 hr per week) had the lowest odds of depressive symptoms (OR=0.76, 95%CI=0.71-0.82) relative to never active women; the OR was 0.90 for women who were active in high school but not adulthood (95% CI=0.85-0.96) and 0.83 for women who were inactive in high school but became actives in adulthood (95% CI=0.77-0.91) (Wise et al., 2006)

A nearest study in 2008 conducted to investigate the 2-week prevalence of depressive symptoms in 802 Hong Kong and 988 Beijing Chinese college freshmen Approximately 8.9% of Beijing had scores on the CES-D of 25 or higher, whereas, 17.6% of freshmen in Hong Kong reported scores of 25 or higher There was no sex difference in prevalence in Beijing The prevalence is significantly different between sexes in Hong Kong in which 13.4% of men having scores of 25 or higher and 21.3%

of women having scores of 25 or higher (Yuqing et al., 2008)

Studies on Medical students

According to the study done by Liselotte N.Dyrbye's, their special articled summarized the central themes of exploring the prevalence, causes, and consequences

as well as strategies to reduce student medical distress by reaching MEDLINE and Pubmed for English article published between 1966 and 2004 Medical student distress, medication, educational environment contain risks element for students' mental health and its specific consequences The various manifestations of medical students that were recorded increasingly and differently for each stage of academic year include stress, depression and burnout Potential causes of student distress mentioned as adjustment to the medical school environment, ethical conflicts, exposure to death and human suffering, student abuse, personal life events, educational debt Obviously, many effects on students involve impaired academic performance, cynicism, academic dishonesty, substance abuse, and suicide The overview analysis is shown following on next page as a model of cause and consequence of medical student distress (Dyerbye et al., 2005)

Some terminologies that closely related to depression and stress as anxiety and burnout that was distinguished follow:

Anxiety

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) defined anxiety as "apprehensive anticipation of future danger of misfortune accompanied by

a feeling of dysphoria or somatic symptoms of tension

Anxiety and depression share common symptoms and can result from similar circumstances, but in theory, at least these two distinguishable Probably, they are

linked, but anxiety suggests arousal and an attempt to cope with the situation; depression suggests lack of arousal and withdrawal A 1991 paper by Clark and Watson proposed a tripartite hierarchical model that holds that anxiety and depression have common, but also unique, features Depression is uniquely characterized by anhedonia and low levels of positive affect referring to loss of pleasure and interest in life, lack of enthusiasm, sluggishness, apathy, social withdrawal, and disinterest Anxiety, meanwhile, is uniquely characterized by physiological hyper arousal, exhibited in racing heart sweating, shakiness, trembling, shortness of breath, and feelings of panic (McDowell, 2006)

Burnout

Burnout is a state emotional and physical exhaustion caused by excessive and prolonged stress It can occur when you feel overwhelmed and unable to meet constant demands As the stress contuse, you begin to lose the interest or motivation that led you to take on a certain role in the first place Burnout reduces your productivity and saps your energy, leaving you feeling increasingly hopeless, cynical, and resentful The unhappiness burnout causes can eventually threaten your job, your relationships, and your health Burnout usually has its roots in stress and its sign tend

to be more mental than physical They can include feelings of powerlessness, hopelessness, emotional exhaustion, detachment, isolation, irritability, frustration, being trapped, failure, despair, cynicism, and apathy (Smith et al., 2007)

Students are subjected to different kinds of stressors, such as the pressure of academics with an obligation to succeed, an uncertain future and difficulties of

integrating into the system The students also face social, emotional, physical, and family problems which may affect their learning ability and academic performance

Figure 2: Proposed model of causes and consequences of student distress

Suicide

FACTORS RELATED TO MEDICAL SCHOOL TRAINING

Workload

Curriculum

Exposure to patient death/suffering

Student's loan debt

System of performance evaluation

(letter grade, pass/fail, etc)

Ethical conflicts

Student abuse (verbal, emotional, etc)

Institutional culture hidden/informal curriculum

POTENTIAL PROFESSIONAL CONSEQUENCES

Impaired academic performance Cynicism/decline in empathy Academic dishonestly Impaired competency Influence specialty choice Attrition from medical school Medical errors

STUDENT DISTRESS

Stress Anxiety Burnout Depression

(66.9%), environment sources as "being placed in unfamiliar situations" (64.2%), and

"waiting long line", "change living environment" that were significantly greater in first year students The most commonly used coping strategies are going along with parent, praying, making one's own decisions, apologizing, helping other people to solve problems, keeping friendships and daydreaming (Seyedfatemi et al., 2007)

According to Marie at el, a cross-sectional study in Institute Medical University, Stockholm, Sweden gave high ratings to the workload and lack of feedback stressors in the first year, female students gave higher ratings than male on many factors (Stress measured by the Perceived Medical School Stress Scale and depression measured by the Major depression inventory) The prevalence of depressive symptoms among students was 12.9%, significantly higher than in the general population, 16.1% among female versus 8.1 among males (Dahlin et al., 2005)

In Nepal, psychological morbidity sources of stress and coping strategy among undergraduate medical students studying 2005, the overall prevalence of psychological morbidity was 20.9% The General health questionnaire, 24 items to assess sources of stress showed that the most important and severe sources of stress were staying in hostel, high parental expectation, vastness of syllabus, test/exam, lack

of time and facilities for entertainment (Screeramareddy et al., 2007)

Kaohsiung Medical University, Taiwan, 2005, correlations between academic achievement and anxiety and depression in medical students experiencing integrated curriculum reform (four blocks in the first semester of the new curriculum) study

approved that there were both positive and negative correlations between academic achievement and anxiety and depression in medical students, regarding differing levels of severity of anxiety or depression, used the Zung’s Anxiety and Depression scale Among the medical students who were in the high depression level group in the second psychological assessment, those who had more severe depression had poorer academic achievement in the fourth learning block differing levels of severity of anxiety or depression (Yeh et al., 2007)

Majority of medical students (175 of 283, approximately 73%) perceived stress publishing by a study of stress in medical students at Seth G.S Medical College and King Edward Memorial Hospital, Parel, Mumbai, India Academic factors were greater perceived case of stress in medical students Emotional factors were found to

be significantly more in first year students as compared to second & third students The Zung's Self – Rating Scale for depression was used to assess the perceived feeling

of the students regarding their emotional status counted score more than or equal to 40

as stress definition (Supe, 1998)

Students mentioned that their overwhelming amounts of information were expected during their first and second year of medical training Moreover, they had difficulty relaxing and engaging in activities normally associated with personal wellbeing The realizably on future was the most stressful of all Questionnaires were mailed to students whose essays were reviewed in a quality study about students' perception of medical school stress and their evaluation of a wellness elective which focused on stress reduction and personal wellness done by Jungkwon Lee and Antonnette V Graham (J Lee et al., 2001)

Female medical students from the general Sweden population in the thesis of Marie Dahlin were more depressed (16.1%), more affected by study stress than their male peers (7.8%) They were also more depressed than women of the same age in the general population (12.9% for common among medical students, 7.8% for general population controls) Study stress was examined by The Higher Education Stress Inventory, prevalence of self-rated depression and suicide ideation/attempts were compared with controls matched by age and sex (Dahlin, 2007)

Using the General Health Questionnaire, it was found that 49.6 percentage encountered significant stress and 64.6 percentages reported that more than 60 percentage of their total life stress was due to medical school The most important psychosocial stressors were: too much work and difficulty in coping That is demonstrated in a cross-sectional study to understanding the psychosocial and physical work environment in a Singapore medical school, 2003-2004 (Chan et al., 2007)

A considerable majority (>90%) think that they had been stressful Females reported more symptoms Academics and exams were the most powerful stressors More leisure time activities, better interaction with the faculty and proper guidance, advisory services and peer counseling at the campus, could do a lot to reduce the stress from study a by Shaikh in Pakistani Medical School, 2004 (Shaikh et al., 2004)

2.4 Site of study

There are two public Medical universities in HMC city Pham Ngoc Thach Medical University is only for students who are residents of HCM city and this university assigns working place for the students after graduate University of Medicine and Pharmacy which is bigger than the other in terms of amount of students and its history is for all students who come from many other provinces The students take the same entrance exam for these universities but each University has different standard grade for recruitment

University of Medicine and Pharmacy at Hochiminh city is the main Medical University for the South of Vietnam locating in HCM city Its responsibility is to train health profession in under graduate to post graduate level, to conduct research, to care for community health as well as to link with international cooperation This public university consists of 982 officers and 659 lecturers of which 7 faculties for 84 departments.This study population chose students in Medical Faculty that is the biggest Faculty containing the most number of students

The University has a hospital in three different locations, one Pharmaceutics Technical Science Centre, six Medical Specialize Centers that apply high technique in treatment as well as medical research In addition, four dormitories serve for 1,500 students each year More than 2,000 students enroll for various health science courses

in technical, college, undergraduate and post graduate degree each year

Table 1: University of Medicine and Pharmacy

Traditional Medicine Faculty 5 Departments

Nurse and Medical Technique Faculty 6 Departments

In two first years, student are learnt the basic sciences and some medical subjects Their curriculum includes 42 credits of physics, chemistry, biology, language, physical exercise, advance mathematics, anatomy and military education in the first term of the first year Each subject takes around more than 11 weeks, then after final exam students starting new subject Generally, students spend 48 hours per week for attending theoretical and practical class

3.2 Study population

Target population of this study was the first year students in Medical

Universities at HoChiMinh city, Vietnam

Study population composed 404 first year students in Medical Faculty in

University Medicine and Pharmacy, Hochiminh city, Vietnam

P = 0.20 : anticipated population (according to previous study, prevalence of

mental health problem in the Vietnamese youth) (Ministry of Health [MOH]-Vietnam, 2005)

n = 246 : minimum sample size

3.4 Sampling technique

Using above formulation for result of 246 subjects and to predict number of absent students or refusing to join this study, sample was added more 10% (24 students) so the total sample included 270 students

Sampling technique: this study was the first study in order to measure the prevalence of depression and related factor among Medical students so a census investigation was conducted with total population of 387 students, though, collected sample was 351 students

3.4.1 Inclusion criteria

The entire 404 first year Medical student in Medical Faculty in University Medicine and Pharmacy, Hochiminh city, Vietnam were chosen in this study

3.4.2 Exclusion criteria

17 repeat students were sort out this study population

3.5 Data collection tool

The questionnaire consisted of 3 parts with 79 questions; the first part was 19 questions about general information, the second part was depression measurement in

20 items of the CES-D questionnaire, and the third was 40 questions about Student stress

The questionnaire was translated into Vietnamese language and versus to make sure the accurateness

3.6 Data collection procedure

Data collection method: self – administrated

Pre-test (pilot) was implemented prior data collection in first year students in other medical university at HoChiMinh city

In the field, data were collected in classrooms with the approval by the Dean

of Medical Faculty The purpose of study was explained to students before delivering questionnaire

Descriptive statistics such as frequency, percentage, mean, and standard

deviation was applied for general characteristics, prevalence depression, sources of medical stress description

Analytical statistics

Bivariate analysis: Chi-square test and Fisher’s Exact test were used

to test the relationship between depression and the students stress sources, and also for relationship between depression and living condition, perception of financial status,

practice of religion, parent's marital status, and exercise/leisure activity, coping with problems, quality of friendship

Non-parametric Spearman correlation was used to find association between 2 continuous variables: depression and age; also between depression scores and total stress scores

Testing of the hypothesis will be performed at 5% level of significances

Multivariate analysis: Logistic regression was applied to find

predictors of effect of multivariable in dichotomous depression variable after controlling confounding factors Level of significant was set at 5%

For depression variable, question scores were summed to provide an overall score ranging from 0 to 60 Four positive questions 4, 8, 12 and 16 were reversed by subtracting the score from 3 If more than 5 items on the scale are missing, a score is generally not calculated

If one to five items on the scale were missing,

Score =

answereditems

number

20

x sum

Depression score was categorized by cut-off point into 2 groups below:

− Scores less than 22 = Non- depressive symptoms group

− Scores are 22 or more = Depressive symptoms group About students stress sources including 40 questions, in non-parametric spearman correlation, students stress scores were summed up as a

continuous variable with non normality distribution In chi-square test, then, students

stress was used separately in each 40 sources to find relationship with depression

Table 2: Variables, measurement scale and statistic inference

Mean, max, min, S.D Frequency, Percentage Frequency, Percentage Frequency, Percentage Frequency, Percentage Frequency, Percentage Frequency, Percentage Frequency, Percentage Frequency, Percentage Frequency, Percentage Frequency, Percentage Depression group

Depression scores

Nominal scale Continuous variable

Frequency, Percentage Mean, Min, Max, S.D Student stress sources

Student stress scores

Binary variable Continuous variable

Number, Percentage Mean, Min, Max, S.D

3.8 Reliability and Validity

Validity

The content and face validity was checked by experts after constructing the

draft questionnaire, special focus on some terms and explanation in translation

English to Vietnamese

Reliability

The reliability was done in pre test on 30 first year students in other Medical university at Hochiminh city Cronbach's alpha coefficient was used to measure reliability of the CES-D questions Cronbach's alpha coefficient for CES-D = 0.775

3.9 Ethical consideration

The questionnaire will be administered anonymously to the student in their classrooms Then, verbally consent information was explained to students before delivering questionnaire They can refuse to join this study without any effects on their study's result and no need to explain the reason Data were used for research's purpose only Their information will be kept confidentially