Abstract
Introduction:
Medical students, interns, and residents have higher rates of depression than the general population, according to previous literature.
Objective:
The objectives of this paper were to determine the rate of depression and its severity in a group of Egyptian residents of Ain Shams University hospitals.
Methods:
This is a cross-sectional comparative study that took place in El-Demerdash Hospital from March 1, 2019 to September 1, 2020, with 220 Egyptian residents of Ain Shams University Hospitals participating.
Results:
The socioeconomic stress scale had a statistically significant relationship with depression scores (p value = .008) and suicide scores (p-value = .010), according to the findings. Additionally, there was a statistically significant relationship between suicide scores and depression scores (p-value = .001). The relationship between obstetrics and gynecology and high suicide risk was statistically significant (p value = .010), with obstetrics and gynecology having the highest percentage of high suicide risk (10 out of 19 residents, 52.63%), followed by pediatrics with 4 out of 11 residents (36.36%).
Conclusion:
The pediatrics department had the highest percentage of residents who were depressed, while the obstetrics and gynecology department had the highest suicide risk. Feeling underpaid, disruption of home life, having insufficient time, being concerned about keeping skills up to date, and having a large volume of work were also found to be the most stressful aspects of residency.
Introduction
Rates of depression are higher in medical students, intern, and residents (15%–30%) than in the general population (Dyrbye et al., 2014; Farrenkopf et al., 2008).
A systematic review and meta-analysis calculated the mean prevalence of depression among residents to be 28.8% ranges from 20.9% to 43.2% (Mata et al., 2015).
Physicians may under-diagnose and under-treat depression and other mood disorders because they are hesitant to seek help or treatment, or to diagnose and treat themselves, or to seek and receive ‘VIP treatment’ from other health care providers. Physicians are often hesitant to seek mental health treatment for their patients (Claudia et al., 2003). Severe depression is common during residency training, according to studies, and certain depressive symptoms, such as anhedonia and job dissatisfaction, are linked to an increased risk of suicide and self-harm in physicians (Loas et al., 2018).
Many are afraid of social stigma and finding a specialist they trust but is not a colleague. Physicians may be concerned about their privacy and fear accusations from colleagues, employers, or licensing boards (Baldisseri, 2007).
Furthermore, perceived medical errors are strongly correlated with physician suicide. Second victim syndrome and physician distress associated with frustration, anxiety, burnout, depression, and suicidality are common (Marmon & Heiss, 2015).
A depressed physician may spiral downward. Several researchers have noted the link between work and self-identity, as well as their impact on physician well-being (Gold et al., 2013). Fear and worthlessness often affect their professional performance. Distressing emotions like irritability and anger strain professional and personal relationships. Changes in a depressed person’s behavior can lead to separation or divorce. Both the patient’s and physician’s care may be jeopardized. Demographic differences between depressed and non-depressed residents were also found (Farrenkopf et al., 2008).
After completing residency, the risk of depression continues. The lifetime prevalence of depression among physicians is 13% in men and 20% in women; these rates are comparable to those of the general population (Frank & Dingle, 1999).
A range of factors were found that predict depression among general practitioners including relationships with senior doctors and patients as well as lack of or decreased sleep, handling or dealing with death, making mistakes, loneliness, 24-hour responsibility and self-criticism (Firth-Cozens, 1998).
Although these stressors increase depression risk, studies showed that they did not increase suicide risk in physicians who did not have underlying psychological difficulties when they entered college. Certain personality traits common among physicians, such as self-criticism and perfectionism, may increase risk for depression and substance abuse (Vaillant et al., 1972).
Although the rate of depression among physicians is comparable to that of the general population, physicians’ risk of suicide is markedly higher. A review of 14 studies found that the relative risk of suicide in physicians compared with the general population is between 1.1 and 3.4 for men and 2.5 to 5.7 for women (Lindeman et al., 1996).
A study of English and Welsh doctors revealed higher suicide rates among female doctors than male doctors (Hawton et al., 2001). Suicidal ideation is 1.5 to 3.0 times more common in surgeons than in the general population (Shanafelt et al., 2011).
We aimed in this study to assess the rate of occurrence of depression and its severity in a sample of Egyptian residents of Ain Shams University hospitals.
Methodology
Search strategy
A cross-sectional comparative study conducted in El-Demerdash Hospital during the period from 1 March 2019 to 1 September 2020 and included 220 Egyptian residents of Ain Shams University Hospitals.
Inclusion criteria
Age range: 23 to 30 year.
Gender: both sexes.
Nationality: Egyptian.
Exclusion criteria
Diagnosed major medical illness.
Residents that received antidepressants for more than 2 weeks before residency.
Procedure of the study
The researcher had interviewed the residents taking a short history then applied these following English version questionnaires:
– SCID I for diagnosis of depression according to the DSM-IV.
– Beck depression inventory.
– Beck suicidal ideations scale.
– The stress part of the modified job stress and job satisfaction questionnaire.
•
It is a clinician-administered semi-structured interview for use in psychiatric patients. It provides a broad coverage of psychiatric diagnosis according to DSM-IV and consists of nine diagnostic modules (mood episode, psychotic symptoms, psychotic disorder differential, mood disorder differential, substance use, anxiety, somatoform disorder, eating disorder, and adjustment disorder). It was designed to be more efficient and simpler to use other than other existing instruments and consequently, to require less time for training and administration (Gorgens, 2011).
The Beck Depression Inventory (BDI)
It is a 21-item self-report rating inventory that measures characteristic attitudes and symptoms of depression and their severity (Beck et al., 1961). The BDI takes approximately 10 minutes to complete, although clients require a fifth to sixth grade reading level to adequately understand the questions.
It is a 21-itemself-report instrument for detecting and measuring the current intensity of the patients’ specific attitudes, behaviors, and plans to commit suicide during the past week. The BSI was developed as a self-report version of the interviewer-administered Scale for Suicide Ideation. The first 19 items consist of three options graded according to the intensity of the suicidality and rated on a 3-point scale ranging from 0 to 2. These ratings are then summed to yield a total score, which ranges from 0 to 38. Individual items assess characteristics such as wish to die, desire to make an active, or passive suicide attempt, duration, and frequency of ideation, sense of control over making an attempt, number of deterrents, and amount of actual preparation for a contemplated attempt. The last two items assess the number of previous suicide attempts and the seriousness of the intent to die associated with the last attempt.
The self-administered questionnaire used for the study was adapted from The Hospital Consultants Job Stress and Satisfaction Questionnaire (HCJSSQ), 2002 customized by Original Research Article (Bagley et al., 2016). The questionnaire consisted of 21 questions on sources of stress, 13 questions on factors contributing to job satisfaction, and 16 questions on methods adopted for coping stress.
Statistical analysis
The statistical analysis was performed using IBM SPSS Statistics version 20. Qualitative variables were presented as numbers and percent, and quantitative variables were presented as means ± standard deviations (SDs).
Results
The whole sample consists of 220 participants. The mean age of the sample was 26.968 ± 1.013. Female residents represented 56.36% of the sample. According to the marital status; the majority were singles (60%). The study included residents that were graduated between year 2013 and 2016, 47.27% were seniors, while 8.64% were fresh residents as shown in Table 1.
Sociodemographic data.
Regarding Beck depression scale, more than quarter of the sample reported normal range of scores, around 24.55% reported mild depression, while extreme depression was found in only 3.18%. Considering Beck suicidal scale scores, 22.73% of the sample recorded high suicide risk, as shown in Table 2.
Distribution of scores of depression, suicide, and socioeconomic stress scales.
Regarding stressful aspects of residency, it was found that feeling poorly paid and disruption of home life through spending long hours at work were of the highest as voted by 78.18% and 77% of residents respectively. Other aspects included having conflicting demands on the residents’ time like patient care, management, or research (72%), feeling concerned about keeping skills up to date (71.38%), and having great overall volume of work (69.5%), as shown in Table 3.
Answers of occupational stress scale questions.
As regards the socioeconomic stress scale, a statistically significant relation was found with depression scores (p value = .008) and with suicide scores (p-value = .010). Also, suicides scores had statistically significant relation with depression scores (p-value < .001), as shown in Table 4.
Relation between Beck depression and other variables (sociodemographic, Beck suicide, socioeconomic stress scale, and ‘residency related SES’ opinion).
According to Beck depression inventory it was found to be statistically significant (p value = .025) with pediatrics department having the least percentage of residents scoring normal (0% out of 13 residents). Meanwhile in extreme depression it was also found that pediatrics department had the highest percentage with 2 out of 11 residents (18.18%), as shown in Table 5.
Relation between depression and different specialty departments.
Regarding Beck suicidal ideation scale, the relation was found to be statistically significant (p value = .010) with obstetrics and gynecology having the highest percentage of high suicide risk (10 out of 19 residents, 52.63%) followed by pediatrics department with 4 out of 11 resident (36.36%) with the least being in the departments not dealing with patients with only 1 out of 25 residents (4%), as shown in Table 6.
The relation between suicidality and different specialty departments.
Discussion
Resident stress, both professional and personal, is a significant and often overlooked factor in their lives. Furthermore, studies have shown that medical students have high rates of depression and suicidal ideation, putting residents at a higher risk for depression (Rotenstein et al., 2016).
And since reliable estimates of depression and suicidal ideation prevalence during medical training are important for informing efforts to prevent, treat, and identify causes of emotional distress among medical students especially in light of recent work revealing a high prevalence of depression in resident physicians, the present study aimed at measuring the rate of occurrence of depression and its severity and the rate of occurrence of suicidal ideation in medical residents at the Faculty of Medicine, Ain Shams University Hospitals and investigating sources of occupational stress as well as measuring the relation between depression, suicidal ideation, and occupational stress.
The study hypothesized that the rate of occurrence of moderate and severe depression would probably be high among medical residents as well as an increased rate of suicidal ideation. This is mostly due to high demands and multiple stressors faced during residency years.
In our study, we found that pediatrics specialty came at the top rank for depression while obstetrics and gynecology residency were the commonest one associated with suicide among residents. This was inconsistent to what as reported in the literature, that anesthesia and psychiatry are the commonest ones associated with stress and suicide (Ventriglio et al., 2020).
By the application of Beck depression inventory (BDI) the current study revealed that 60 residents (27.27%) meeting the inclusion criteria had normal ups and downs, while 160 residents (72.73%) reported depression scores with different severity ranging from mild (n = 54, 24.55%), borderline (n = 38, 17.27%), moderate (n = 51, 23.18%), severe (n = 10, 4.55%), and extreme (n = 7, 3.18%).
This is in accordance with the study done in Lebanon as a total of 26 participants (22%) showed moderate to severe depressive symptoms, and another 35 participants (30%) showed mild depressive symptoms on the PHQ-9 (Talih et al., 2016).
And in contrast to the study done in Ain Shams University hospitals in 2014 that showed out of 47 residents, 19 residents had mild mood disturbance (40.4%), 28 had moderate to severe depressive symptoms (59.6%) (Al-Sayed et al., 2016).
On using the Beck suicidal ideation scale, the current study findings demonstrated that 50 residents (22.7%) out of the 220 residents recorded a riveting rate of high suicide risk, these findings were close to studies that showed large discrepancy in prevalence of depressive symptoms ranging from 1.4% to 73.5%, and those of suicidal ideation vary from 4.9% to 35.6% (Osama et al., 2014; Yu-hui et al., 2012). Kessler and coworkers estimate that 5% of employees have workplace mood disorders. About 6.4% had M.D. (MDD) (Woo & Postolache, 2008). A recent study found that 4.6% of 24,000 working Canadians had a major depressive episode. An MDE affected 7.0% of full-time adult workers last year, according to the OAS (Blackmore et al., 2007).
However, our results were in contrast with a study done on American surgery residents that showed of the 7,905 participating surgeons (response rate, 31.7%), 501 (6.3%) reported suicide ideation during the previous 12 months (Shanafelt et al., 2011). This may reflect the high socioeconomic level among American residents in addition to better work environment subjected to less pressure or other stressing factors found in our hospital environment.
On the other hand, our results were in consistence with a study done in Australia between 2013 and 2019, in which 24.8% of participants reported thoughts of suicide through the past 12 months prior to participation on the study (Wu et al., 2013). Unfortunately, 2% of those participants attempted suicide other than just ideations unlike ours, where no suicidal attempts were reported by physicians. This may be due to the religious thoughts common in our community.
Prevalence of psychiatric disorders differ among physicians according to the work environment that differ from one place to another. In our study, the major stressors faced by physicians were poor economic outcome and home disruption having long hours away from home which were reported by 78.18% and 77% of participants. In concordance, doctors who recently contemplated suicide were five times more likely to report personal problems, three times more likely to report financial problems, and roughly two times more likely to report health or work problems than those not thinking about suicide. In contrast, they found that lack of social support and teamwork were the most common risk factors for depression and other psychiatric morbidities in Western countries (Firth-Cozens, 2000). Also, most studies have linked low family and peer support to variable risk of depression (Bettge et al., 2008; McDonald et al., 2010; Väänänen et al., 2014).
In accordance with the study done in Ain Shams University Hospitals in 2014 that showed the most stressful aspect to residents was having too great overall volume of work (78.7%), then comes inadequate administration systems (76.6%), followed by disruption of social life due to spending long hours at work (74.5%) (Al-Sayed et al., 2016).
A residency was not found to have any statistical significance regarding depression and suicidality. Equal measures were found in residents despite years spent. On the contrary a recent study showed the risk for death by suicide was higher early in residency and during certain months of the academic year (Yaghmour et al., 2017).
However, as regard socioeconomic stress it was found to be significantly related to depression (p value = .008) and to suicide (p-value = .010). While suicide was evidently found to be related to depression (p-value < .001) in concordance with the study done on Lebanon that showed suicidal ideation occurred significantly more often among those with major depressive symptoms (12/15 = 80%) compared to those with mild depressive symptoms (2/15 = 13.3%) (Talih et al., 2016).
Limitations
First; the study design was a cross-sectional study that only took a snap-shot view of the studied outcomes; therefore, it is difficult to be generalized as there might be other factors affecting the results like ongoing personal experiences and practices in psychiatry field that students might get exposed to on the long run.
Second; the residents were divided according to their specialties into five groups, and specialty categories ended up in relatively small numbers in each department that limited some statistical analysis.
Third; the tools used in the study were time consuming and this was the main cause of non-cooperativeness of residents either from the beginning or shortly after participating in the study.
Conclusion
Medical residents have remarkable work stress that has its impact on their psychological health in the form of anxiety and depressive symptoms that may affect their quality of life and the quality of services they provide to their patients.
Medical residents who are usually dealing with inpatient type of work are more vulnerable to work stress than those who do not.
Pediatrics department were found to have the highest percentage of depression among residents, while obstetrics and gynecology department were estimated to be with the highest suicide risk.
The most stressful aspects of residency were found to be feeling poorly paid, disruption of home life, having insufficient time, feeling concerned about keeping skills up to date, and having a great volume of work.
Recommendations
Causes of stress within the medical residents should be thoroughly identified in order to cease them or decrease their negative impact on the health of the medical residents and their work outcome.
Medical departments especially the pediatrics and obstetrics and gynecology department should reconsider the psycho-social support given to medical residents consistent with their work nature, token economy (positive reinforcement by rewarding and praise) and the resting hours needed during the working shifts for a better medical service outcome given to patients.
Footnotes
Acknowledgements
The authors would like to thank medical staff in Ain Shams University Hospitals for their kind help.
Data sharing
The data underlying this article will be shared on reasonable request to the corresponding author.
Ethical consideration
An oral consent was asked from each patient participating in the study (the study was explained to the patient or his legal guardian). This study was approved from the ethical committee of neuropsychiatry department.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
