ORIGINAL PAPER

The Prevalence of Depression Among Medical

Students
Sherina MS, Nadarajan Kaneson
Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Puts Malaysia.

The objective of this study was to determine the prevalence of depression among
medical students at a local university in Malaysia. A cross-sectional study design
was used. The Beck Depression Inventory (SDI) was used as a screening Instrument
among all medical students of University Putra Malaysia (UPM) at the Faculty of
Medicine and Health Sciences. 35.9% of UPM medical students were found to have
depression. Factors found to have significant association with depression were
females (+ 2 m8.467, df=1, p<0.05), Malays
2
(+ 2 =11.509, df=1, p<0.05), relationship of the
respondents with their siblings (+ x.882, df=1, p<0.05), pressure prior to exam
(+ 2 =9.443, df=1, p<0.05) and problems with love (boy-girl) relationship (+2=10.068,
df=1, p<0.05). The prevalence of depression among medical students was high. Early
detection of this condition Is Important to prevent psychological morbidity and its
unwanted effects In medical students and young doctors.

Key-words : Depression, medical students, associated factors, Unlversiti Putra

Malaysia, Malaysia

Malaysian Journal of Psychiatry March 2003, Vol. 11, No. 1

Introduction It is one of the major problems among students and

Medical school is recognized as a stressful
environment that often exerts a negative effect on the
academic performance, physical health and
psychological well-being of the student. A study
among 69 third year medical students at the University
of Mississippi School of Medicine, USA, reported
that 23% had clinical levels of depression and 57%
had emotional disorders (1). Medical students are
expected to learn and master a huge amount of
knowledge and skills. The personal and social
sacrifice they have to make in order to maintain good
academic results in a highly competitive environment
puts them under a lot of stress (2).
Emotional disorder is defined as feelings of
sadness and tiredness in response to stressors in life.
Correspondence:
Dr. Sherina Mohd. Sidlh, Lecturer, Unit of Family Medicine,
Department of Community Health, Faculty of Medicine and Health
Sdeocee, Uulvenitl Putra Malaysia, 43400 serdang, Selangor, Malaysia.
consists mainly of depression and anxiety disorders.
A study among medical students in Singapore has
shown that stress is significantly associated with
emotional disorders among medical students (3).
Malaysia's quest to be the centre of excellence
may see many students developing to their fullest
intellectual potential, but also have others "breaking
down". These psychological casualties are a waste of
valuable human resource. The objective ofthis study
was to determine the prevalence ofdepression among
medical students at a local university in Malaysia and
to identify its associated factors.
Material and Method
A cross sectional study was conducted in the
Faculty ofMedicine and Health Sciences, University
Putra Malaysia (UPM), Malaysia over 3 months, from
JunetoAugust2002.All medical students ofUPMwere
selected as respondents. Data was collected using the

12
 THE PREVALENCE OF DEPRESSION AMONG MEDICAL STUDENTS
Beck Depression Inventory (BDI) questionnaire. The
BDI is a2 1 item self-report rating inventory measuring
characteristic attitudes and symptoms of depression
(4). The BDI was pre-tested in another faculty in
UPM. The questions consisted of 2 parts. Part 1 was
based on factors such as gender, ethnicity, year of
study in medical school, relationship of respondents
with their parents, siblings, lecturers, course mates
and pressure prior to exam. Part 2 consisted of the
$DI questionnaire.
The SD! questionnaire consisting of 21 questions
was used as the study instrument. Each question had
4 responses. The participants' answers were scored
as 0-1-2-3 based on their responses. The total score
was determined by adding the score obtained for each
answer in the questionnaire. Based on the BDI
guidelines, scores of 11 and above were considered
to be positive for depression. Data was analyzed
using the Statistical Package for Social Sciences
programme version 10.0. The statistical tests
employed were the chi-square test, fisher-exact test
and t test. The level of significance used for the above
data wasp <0.05.
Results
Out of414 medical students, 396 students completed
the questionnaires giving a response rate of 95.6%.
Their mean age was 21.55 years (SD=1.95) with 244
(61.6%) females and 152 (38.4%) males. Majority
were Malays (53.0%) followed by Chinese (36.1%),
Indians (6.8%) and other races (4.1%).
Based on the BDI scores, the prevalence of
depression among UPM medical students was 35.9%.
Table I shows the prevalence of depression
among UPM medical students and its associated
factors. This study found that depression among
medical students were significantly associated with
the female gender, Malays, level of pressure due to
exam, relationship of the students with their siblings
and problems in love (boy-girl) relationship. The
prevalence of depression was significantly higher in
female students (41.4%) compared to males (27.0%),
Malays (42.9%) compared to other races (26.5%)
and in students who complained of pressure due to
exams (42.7%) compared to those who did not
complain of any pressure due to exams (27.9%). The
prevalenceofdepressionwas also significantly higher
in students who did not have good relationship with
their siblings (49.1%) compared to students who had
good relationship with their siblings(33.7%). Students
who had problems in love (boy-girl) relationships
(51.3%) were also significantly more depressed
compared to students who had rio problems (31.6%).
Students who did not have good relationship
with theirparents (43.5%) had a higher prevalence of
depression compared to students who had good
relationship with their parents (34.9%). The
prevalence of emotional disorders was also higher
among students who did not have good relationship
with their lecturers (37.4%) compared to students
who had good relationship with their lecturers
(33.1%), and in students who did not have good
relationship with their coursemates(37.9%) compared
to those who had good relationship with their
coursemates (34.7%).
Analysis of depression with year of study in the
medical school found that the prevalence ofdepression
was highest among Year! students (41.0%), followed
by Year 4 students (40.8%). However, all the above
differences were not found to be statistically
significant.
Discussion
Medicine has always been regarded as a popular
choice in tertiary education. There has always been
an excess of applicants over available places, with
successful candidates having excellent academic
results which makes it even more competitive and
stressful for students who are accepted (3).
This study found that the prevalence ofdepression
among medical students was high (35.9%). Other
studies among medical students have also documented
a high level of depression and emotional disorders
among these students (1,3,5).
The prevalence of depression was higher among
female medical students compared to males in this
study. Other studies in the community and general
practice have also found that depression is more
common among females than males (6,7,8).
13
 SHERINA MS d al '

Table 1: Factors associated with depression among UPM Medical Students

Associated Depression No Depression p value

Factors (n=1 42) (n=254)

Gender
Female 101(41.4%) 143(58.6%) *p<0.05
Male 41(27.0%) 111(73.0%)

Ethnicity
Malays 90(42.9%) 120(57.1%) 'p<0.05
Chinese 43(30.1 %) 100(69.9%)
Indians 7(25.9%) 20(74.1%)
Others 2(12.5%) 14(87.5%)

Pressure due to exam

Yes 91(42.7%) 122(57.3%) 'p<0.05
No 51(27.9%) 132(72.1%)

Good relationship with siblings

Yes 115(33.7%) 226(66.3%) p<0.05
No 27(49.1%) 28(50.9%)

Problems with (Boy-Girl) relationship

Yes 40(51.3%) 38(48.7%) 'p<0.05
No 43(31.6%) 93(68.4%)

Good relationship with parents

Yes 122(34.9%) 228(65.1%) p>0.05
No 20(43.5%) 26(56.5%)

Good relationship with lecturers

Yes 46(33.1°/,) 93(66.9%) p>0.05
No 96(37.4%) 161(62.6%)

Good relationship with coursemates

Yes 87(34.7%) 164(65.3%) p>0.05
No 55(37.9%) 90(62.1%)

Continue Table 1: Factors associated with depression among UPM Medical Students

Associated Emotional No Emotional p value

Factors Disorders Disorders
(n=166) (n=230)

Year of study in medical school

First 43(41.0%) 62(59.0%) p>0.05

Second 22(30.1%) 51(69.9%)
Third 31(36.9%) 53(63.1%)
Fourth 31(40.8%) 45(59.2%)
Fifth 15(25.9%) 43(74.1%)

p<0.05 is significant

14
 THE PREVALENCE OF DEPRESSION AMONG MEDICAL STUDENTS
This study also found that depression had the highest
prevalence among the Malay medical students
compared to other races. A local study in an urban
general practice conducted by T.Maniam found that
Malays had the highest rate of emotional disorders
(which mainly consists of depression ) compared to
other races in Malaysia (9).
This study found that depression was significantly
associated with pressure prior to exam. A study on
medical students in Singapore showed that medical
students reported a higher level ofstress and emotional
disorders compared to students from other faculties.
At least seven out of every ten medical students
complained ofstress related to academicpursuits (eg.
difficulty in keeping up with readings, increased
academic workload, etc.) The long hours, as well as
difficulty in lectures and tutorials among medical
students could be due to information overload.
Academic stress and its related matters ranked top
eight among the ten most common stressors for all
students. This is understandable as the main concerns
at this point of students' lives are related to academic
work (3).
Students who had problems in their (boy-girl)
relationships had higher prevalence of depression
compared to those without problems in their
relationships. Medical students are of the age when
love relationships become increasingly important.
Problems in these relationships may make it more
difficult for these students to cope with their other
problems (3).
In this study, students who had poor relationship
with their siblings were significantly more depressed
than students with good relationship with their
siblings. Students who had poor relationship with
their parents were also more depressed than students
with good relationship with their parents. This is
because family (parents and siblings) are an important
source of support to our students. Parents are usually
a source of financial and emotional support, while
siblings serve as confidantes for emotional problems
(3). Therefore students with good relationships with
their siblings and parents are less likely to develop
depression due to a better level of support from their
families.
Students who had poor relationship with their
coursemates were also more depressed than students
with good relationship with their coursemates in this
study. A study in Singapore found that medical
students coped with their problems by confiding in
their friends / coursemates and families When faced
with a problem, many medical students would turn to
their friends and coursemates for assistance (3).
Students with good relationship with their
coursemates are probably less likely to develop
depression as they are able to copewith their problems
by confiding in their coursemates.
This study also found that students who had poor
relationship with their lecturers were more depressed
than students with good relationship with their
lecturers. Another study reported that emotional
disorders in medical students was caused by
uncertainties abouttheir lecturers' expectations which
led to uncertainties about their academic performances
(5). Students who do not have good relationships
with their lecturers are probably more likely to be
uncertain about their lecturers' expectations which
negatively affects their academic performances. This
may lead to the development of depression in this
group of students.
In this study, depression was most common
among the first year medical students compared to
other years. The first year is particularly trying for
many students, having to adjust quickly to a fast-
paced and highly competitive environment, and to
master a large amount of complex materials. For
instance, the teaching of Anatomy, Physiology and
Biochemistry requires medical students to absorb
lots ofnew and factual information. When they fail to
perform adequately during tests or assignments, they
become depressed. A study of 128 first year students
at the Louisiana State University School ofMedicine,
New Orleans, found that hassles at the beginning of
the year were associated with poor health outcomes
at the beginning and end of the year (10).
The curriculum in tertiary education have always
come under strong criticism for being grossly
overcrowded with information. Much of this large
bodyoffactual knowledge is acquired largely through
passive learning by the students (11). With the advent
15
 SHERINA MS et al
of information technology, much information can
now be accessed by electronic means. Therefore,
universities should begin embarking on reducing
information overload in its curriculum. Students
should be taught on self-learning and critical thinking
skills, to enable them to deal more effectively with
the changes in their professional lifetime (3).
When examining the stress ofinedical education,
the General Professional Education of Physician
(GPEP) Report, Association of American Medical
Colleges, suggested enhancing the personal
development of each student, establishing mentor
relationships and placing a greater emphasis on health
programmes including stress management, in order
to help students cope with the stress of tertiary
education. Students who are prepared with more
realistic expectation in their academic pursuits,
togetherwith a moremanageablecurriculum, coupled
with stress management techniques and good social
support would have an advantage in coping (12). In
this respect, medical faculties should introduce
Foundation Courses for new students, to provide an
overviewofwhatto expectin medical school. Lectures
on study techniques, stress and time management
should also be given. And to offer a more balanced
medical education, talks on what life is like in the
faculty, medical history, and the science and art of
medicine should also be given (3). The ultimate aim
is to help our medical students understand what is
required of them and to adapt as quickly as possible.
Student Mentorship Programmes have been set
up by most medical faculties including Universiti
Putra Malaysia, which offers consultation to students
who may need assistance by academic staff. As most
students turn to their coursemates for support, it
would also be beneficial to include senior medical
students in these Mentorship programmes, where the
seniormedical students can be mentors to theirjunior
coursemates. This will help new medical students
especially those in Year 1 to adjust as best as possible
with the university education and life-style (3).
Studies on emotional disorders (including
depression) in medical students have found that these
disorders are under diagnosed and under treated.
Failure to detect this disorders will unfortunately
lead to increase psychological morbidity with
16
unwanted effects throughout their careers and lives
(5). The above measures should be implemented in
order to eradicate or minimize depression as well as
other emotional disorders at an early stage for a better
quality of life among medical students.
Conclusion
Depression is common among medical students. The
prevalence of depression was found to be higher
among female students, Malays, students who
complained of pressure due to exams, students who
did not have good relationship with their siblings and
students who had problems in their love (boy-girl)
relationships. It is important to detect depression at
an early stage so that treatment can be given to those
affected and psychological morbidity with its
unwanted effects can be prevented among our medical
students and young doctors.
Acknowledgement
We thank Associate Professor Dr Lekhraj Rampal
for his help and support in conducting this study. We
also thank Professor Dr Azhar Md Zain, Dean of
Faculty ofMedicine and Health Sciences, University
Putra Malaysia, for his encouragement and permission
to publish.
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