Asian Journal of Psychiatry 56 (2021) 102548

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Asian Journal of Psychiatry

journal homepage: www.elsevier.com/locate/ajp

Depressive symptoms in residents of a tertiary training hospital in Malaysia:

The prevalence and associated factors
Navin Nair *, Chong Guan Ng, Ahmad Hatim Sulaiman
Department of Psychological Medicine, Faculty of Medicine, University Malaya Medical Centre, Jalan University, 59100, Kuala Lumpur, Malaysia

A R T I C L E I N F O A B S T R A C T

Keywords: The mental wellbeing of doctors is becoming an increasing concern in the world today. In Malaysia, residency is a
Doctors challenging period in a doctor’s life, with many changes professionally and possibly in their personal lives as
Residents well. This study aims to determine the prevalence of depressive symptoms and the socio-demographic correlates
Depression
among residents in a tertiary training hospital in Malaysia. It is a cross sectional study and all residents were
Long working hours
Study time
approached to participate in the study. The instruments used were a socio-demographic questionnaire and the
Malaysia Patient Health Questionnaire 9 (PHQ-9). Chi-square test was used to explore the association between the socio-
demographic correlates, and those that were found to have significant associations were further tested using
multivariate logistic regression. The prevalence of depression among residents was 25.1 %. Longer working
hours, missing meals, and working in Department of Surgery and Department of Anaesthesia was significantly
positively associated while having protected study time, CME/lectures, leisure/hobbies and exercise were
negatively associated with depression. The Department of Rehabilitation Medicine had a significantly negative
association with depression. After logistic regression, longer working hours and a lack of protected study time
was significantly associated with depression in the respective departments. In summary, the prevalence of
depression among residents is high and is associated with longer working hours, missing meals and a lack of
protected study time are significantly associated with depression. Remedial steps should be taken to improve the
mental health among residents.

1. Introduction relationships were found to be significantly associated with depressive

There has been an increasing concern towards the mental wellbeing
of doctors in the world today, with an increase of mental health disor­
ders especially depression (Kumar, 2016). Depression has a worryingly
high prevalence among doctors, and can be potentially hazardous to
good medical practice (Tomioka et al., 2011).
Multiple factors have been found to be associated with the high rates
of depression among doctors. In one study, almost one in six doctors
were suspected of having depression while being female and in the first
year of specialty training was associated with higher levels of depressive
symptoms (Demir et al., 2007). This was similar to a study done by
(Sasidharan et al., 2016) where the prevalence of depressive symptoms
was high among doctors, and especially so among female doctors.
However, while another study by (Onyeama et al., 2015) had also found
a high prevalence of depression among resident doctors, they had found
that there was no difference between gender. Among doctors working in
intensive care units in France, workload and poor interpersonal
symptoms (Embriaco et al., 2012). Thus, it would be important to
explore the prevalence and the significant associations among resident
doctors.
While there have been a few studies done among medical students
and housemen/interns in Malaysia, studies done on resident doctors
have been extremely scarce. Resident doctors for the purpose of this
study are defined as those who are currently in the post graduate
training program, in comparision to medical officers, who are not in the
program. It is hypothesized that this particular group of doctors can be
susceptible to higher levels of burnout and stress, as there are many
changes happening in their lives during this critical period such as
adjusting to a new environment, taking on new knowledge and honing
existing skills, and possibly changes in their personal lives as well. Most
resident doctors would possibly age between 28–35, which also co­
incides with a period of personal growth, in terms of finding a partner,
settling down, getting married and having children. Hence, this study
aims to study the rates of depressive symptoms among residents in

* Corresponding author at: 11A, SS21/29, Damansara Utama, 47400, Petaling Jaya, Selangor, Malaysia.
E-mail address: navinnnair@yahoo.com (N. Nair).

https://doi.org/10.1016/j.ajp.2021.102548
Received 9 July 2020; Received in revised form 10 December 2020; Accepted 5 January 2021
Available online 11 January 2021
1876-2018/© 2021 Elsevier B.V. All rights reserved.
N. Nair et al.
University Malaya Medical Centre (UMMC) as there is a lack of data
among this particularly vulnerable population. Furthermore, this study
aims to be a pilot study, and data collected can be used to design future
studies which can be multi-centred, and more in-depth.
2. Methods
2.1. Sample
This study was done in UMMC, which is the oldest and most estab­
lished tertiary training hospital situated in the capital of Malaysia. It is
cross sectional in nature and aimed to be all inclusive in terms of sam­
pling method. The residents were approached through their head of
departments.
2.2. Procedure
Ethical approval was first obtained from the Ethical Committee of
UMMC and permission was sought from the head of departments to
approach all their residents. 224 residents who fit the inclusion criteria
(could understand English, currently pursuing specialization in UMMC)
and consented to be in this study completed the questionnaires in front
of the principal investigator to ensure confidentiality. Those with PHQ 9
scores that were of concern was encouraged to seek help at the psychi­
atric walk in clinic.
2.3. Materials
Two questionnaires were used in this study, the socio-demographic
questionnaire and the PHQ-9, both of which were developed in English.
The socio-demographic questionnaire was divided into 2 parts; the
first part which contained basic demographic details such as age, sex,
marital status, number of children, medical history, psychiatric history
and family history of psychiatric illness, smoking, alcohol use, current
place of residence, number of residents as well as total household in­
come. The second part contained work characteristics such as number of
hours worked, area of specialization, number of on calls a month, time
taken travelled to work and number of missed meals a week due to work.
Other factors which would be important to a resident such as number of
protected study hours, number of lectures/continuous medical educa­
tion (CMEs) as well as factors that would affect work life balance such as
average hours of sleep, exercise and leisure per week were included in
the questionnaire.
Symptoms of depression was assessed using the PHQ-9 which is a
depression module of the longer Patient Health Questionnaire (PHQ)
which was developed in 2001 and can be used to measure the severity of
depression with good reliability and validity, making a good and useful
research tool (Kroenke et al., 2001). While it can be used as a diagnostic
tool for depression, the PHQ is best used as a screening tool for
depression followed by a more formal assessment (Wittkampf, 2010). It
is self-administered, is shorter than other depression questionnaires with
comparable specificity and sensitivity (Kroenke and Spitzer, 2002). It
has 9 items, covering anhedonia, low mood, sleep and appetite distur­
bances, energy levels, difficulty concentrating, feeling of being a failure,
changes in movement as well as thoughts of death, self-harm and sui­
cide. These items are then graded based on the frequency, ranging from
0 being never, to 4 being nearly every day. The total score is then
computed, and the recommended cut off point of 10 or more for major
depression, with a sensitivity of 88 % and also a specificity of 88 % as per
the recommendations by the authors. The participants are further sub­
divided according to severity, using cut-off points recommended by the
Kroenke et al. Those with scores between 0–4 were considered to be
normal, while scoring between 5–9 were mild, 10–14 were moderate,
scores 15–19 were moderate to severe depression, while scores of above
20 were categorised as severe depression.
2
Asian Journal of Psychiatry 56 (2021) 102548
2.4. Data analysis
Statistical Package for Social Science (SPSS) Version 23 was used to
analyse the data in this study. Data cleaning was done to detect any
missing values or coding errors. Descriptive statistics was used to
calculate the general characteristics of the participants involved.
Continuous type variables were described using mean and standard
deviations while categorical type variables were presented using fre­
quency and percentage. Continuous variables were divided into two
using their mean to enable univariate analysis using chi-square. Chi
square tests were used to analyse the association of risk factors with the
development of depression symptoms, burnout, job and life satisfaction.
Departments with p values less than 0.05 for depressive symptoms,
burnout, job and life satisfaction were further subjected to multivariate
analyses.
3. Results
All residents working in the hospital were approached for this study
through their head of departments. However, while exact response rates
were difficult to be determined due to the constant change of doctors
working in the hospital, response rates are estimated to be around 50 %
using departmental data. A total of 224 residents participated in this
study. The mean age of the participants was 32.72 years old and there
were slightly more females (53.6 %) compared to males (46.4 %). In
terms of ethnicity, Chinese made up 45.1 % of the participants, followed
by the Malays at 35.7 %, Indians at 16.5 %, and other minority eth­
nicities at 2.7 %. Most of the participants were married (65.6 %) and
their partners’ had a mean age of 33.37 with 47.7 % of them were
married to doctors. Among the residents, 55.4 % had no children while
44.5 % had at least one child. When it came to their health, 9.4 % of
them reports a pre-existing medical illness, while 4% of them had a pre-
existing psychiatric illness, with 6.7 % reporting a family history of
psychiatric illness in the family. 16.1 % of the participants do consume
alcohol while 1.3 % are smokers. When it comes to their accommoda­
tion, around 43.8 % stay in apartments, 41.5 % in houses, 11.2 % in
single rooms and 3.6 % of the participants stay in a single room. Most
live with family (64.3 %), 17.4 % live alone, while 7.6 % live with
friends. The mean number of residents was 4, with a mean household
income of RM11724.75.
When it comes to job characteristics, the mean number of years
working was 7.96. Among the participants, the most number of partic­
ipants came from the Department of Anaesthesia (12.5 %), while the
least number of participants came from the Orthopaedics Department
(4.5 %). There were 18.3 % currently in first year, 14.7 in second year,
31.3 in third year, and 35.7 in final year of their residency. The mean
number of working hours was 56.44 per week, with an average of 3.55
on calls or night shifts per month, with 35.6 % having relief after an on
call or a night shift, and 64.4 not having any relief. They experienced a
mean of 1.63 deaths per month in the course of their work. Otherwise,
when it comes to their training, post graduate trainee doctors have
3.82 h of protected study time and 5.22 h of Continuous Medical Edu­
cation (CME) or lectures per week on average. Post graduate trainee
doctors also spend an average of 5.22 h on leisure and 1.87 h doing
exercise per week. Regarding sleep, post graduate trainee doctors sleep
an average of 41.74 per week.
When results of the PHQ-9 were tabulated, 41.5 % of them scored
between 0–4, which were categorised as normal. 33.5 % were cat­
egorised as mild, 18.8 % were moderate, 3.6 % were moderate to severe,
while 2.7 % were severe. Prevalence was found to be 25.1 %, using the
predetermined cut-off value of 10. When univariate analysis was done
(Table 1), residents in the department of surgery (p-value:0.047, OR:
2.489) and the department of anaesthesia (p-value: 0.001, OR: 3.667)
were significantly associated with higher rates of depression, while the
department of rehabilitation medicine was significantly associated with
lower rates of depression (p-value:0.038, OR: 0.152). Other significant
N. Nair et al. Asian Journal of Psychiatry 56 (2021) 102548

Table 1
Sociodemographic Data and Results of PHQ-9.
PHQ score less than PHQ score 10 and X2 Odds P value 95 % Confidence
10 (n%) above (n%) Ratio interval

Age (32.72±1.95) 0.054 0.931 0.816 0.507− 1.709

Below 33 103 78 (75.7) 25 (24.3)
(46.0)
33 and above 121 90 (74.4) 31 (25.6)
(54.0)
Gender 3.446 0.556 0.063 0.964− 3.36
Male 104 84 (80.8) 20 (19.2)
(46.4)
Female 120 84 (70.0) 36 (30.0)
(53.6)
Ethnicity
Malay 80 (35.7) 61 (76.3) 24 (23.8) 0.104 0.901 0.747 0.477− 1.702
107 (74.3) 32 (26.0)
Chinese 101 77 (76.0) 24 (23.8) 0.150 0.886 0.698 0.482− 1.631
(45.1)
91 (74.0) 32 (26.0)
Indian 37 (16.5) 25 (67.6) 1.306 1.560 0.253 0.725− 3.358
143 (76.5) 12 (32.4)
Others 6 (2.7) 5 (100.0) 44 (23.5) 1.705 1.344 0.335* 1.243− 1.452
163 (74.4)
0(0.0)
56 (25.6)
Relationship Status 1.906 1.599 0.167 0.819− 3.122
147
Married 106 (72.1) 41(27.9)
(65.6)
Unmarried 77 (34.4) 62 (80.5) 15 (19.5)
Age of Partner (33.7±3.01) 0.261 0.819 0.609 0.380− 1.765
Below 33 53 (35.8) 40 (75.5) 13 (24.5)
33 and above 95 (64.2) 68 (71.6) 27 (28.4)
Occupation of Partner 1.168 1.491 0.28 0.721− 3.083
Doctor 72 (47.7) 50 (69.4) 22 (30.6)
Non-Doctor 79 (52.3) 61 (77.2) 18 (22.8)
Children 0.385 1.212 0.535 0.661− 2.222
100
Yes 73 (73.0) 27 (27.0)
(44.6)
124
No 95 (76.6) 29 (23.4)
(55.4)
Medical Illness 1.419 0.472 0.234 0.134− 1.666
Yes 21 (9.4) 18 (85.7) 3 (14.3)
203
No 150 (73.9) 53 (26.1)
(90.6)
Psychiatric Illness 0.000 1.000 1.000* 0.102− 9.812
Yes 4 (1.8) 3 (75.0) 1 (25.0)
220
No 165 (75.0) 55 (25.0)
(98.2)
Family History of Psychiatric illness 0.214 0.736 0.643 0.200− 2.708
Yes 15 (6.7) 12 (80.0) 3 (20.0)
209
No 156 (74.6) 53 (25.4)
(93.3)
Smoker 1.014 1.339 0.575* 1.240− 1.446
Yes 3 (1.3) 3 (100.0) 0 (0.0)
221
No 165 (74.7 56 (25.3)
(98.7)
Consumption of Alcohol 0.706 1.398 0.401 0.638− 3.063
Yes 36 (16.1) 25 (69.4) 11 (30.6)
188
No 143 (76.1) 45 (23.9)
(83.9)
Current Residence
S ingle Room 25 (11.2) 17 (68.0) 8 (32.0) 0.735 1.480 0.391 0.601− 3.644
151 (75.9) 48 (24.1)
Apartment 98 (43.8) 70 (71.4) 28 (28.6) 1.185 1.400 0.276 0.763− 2.569
98 (77.8) 28 (22.2)
House 93 (41.5) 73 (78.5) 20 (21.5) 1.036 0.723 0.309 0.387− 1.352
95 (72.5) 36 (27.5)
Hostel 8 (3.6) 8 (100) 0 (0.0) 2.765 1.350 0.206* 1.248− 1.461
160 (74.1) 56(25.9)
Co-inhabitants
Alone 39 (17.4) 28 (71.8) 11 (28.2) 0.259 0.917 0.611 0.286− 2.937
140 (75.7) 45 (24.3)
Friends 17 (7.6) 13 (76.5) 4 (23.5) 0.021 1.090 1.000* 0.340− 3.491
155 (74.9) 52 (25.1)
Housemates 24 (10.7) 17 (70.8) 7 (29.2) 0.249 1.269 0.618 0.497− 3.240
151 (75.5) 49 (24.5)
(continued on next page)

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N. Nair et al. Asian Journal of Psychiatry 56 (2021) 102548

Table 1 (continued )
PHQ score less than PHQ score 10 and X2 Odds P value 95 % Confidence
10 (n%) above (n%) Ratio interval

Family 144 110 (76.4) 34 (23.6) 0.415 0.815 0.520 0.437− 1.520
(64.3)
58 (72.5) 22 (27.5)
Number of Residents (4±3.15) 0.097 0.908 0.755 0.493− 1.669
Below 4 106 80 (75.5) 26 (24.5)
(48.0)
4 or More 115 85 (73.9) 30 (26.1)
(52.0)
Household Income (11724.75±6347.73) 0.005 1.024 0.944 0.529− 1.981
Below 12,000 107 81 (75.7) 26 (24.3)
(54.9)
12,000 or more 88 (45.1) 67 (76.1) 21 (23.9)
Working Years (7.96±1.66) 0.772 0.751 0.38 0.395− 1.425
Below 8 128 97 (75.8) 31 (24.2)
(57.1)
8 and more 96 (42.9) 71 (74.0) 25 (26.0)
Area of Specialization
Medicine 21 (9.4) 14 (66.7) 7 (33.3) 0.858 1.571 0.354 0.600− 4.115
154 (75.9) 49 (24.1)
Surgical 21 (9.4) 12 (57.1) 9 (42.9) 3.941 2.489 0.047 0.988− 6.270
156 (76.8) 47 (23.2)
Paediatrics 16 (7.1) 13 (81.3) 3 (18.8) 0.359 0.675 0.766* 0.185− 2.460
155(74.5) 53 (25.5)
Ophthalmology 12 (5.4) 11 (91.7) 1 (8.3) 1.878 0.260 0.303* 0.033− 2.057
157 (74.1) 55 (25.9)
Psychiatry 25 (11.2) 17 (68.0) 8 (32.0) 0.735 1.480 0.391 0.601− 3.644
151 (75.9) 48 (24.1)
22 (9.8) 20 (90.9) 2 (9.1) 3.293 0.274 0.070 0.062− 1.212
Emergency Medicine
148 (73.3) 54 (26.7)
Rehabilitation Medicine 19 (8.5) 18 (94.7) 1 (5.3) 4.313 0.152 0.038* 0.020− 1.162
150 (73.2) 55 (26.8)
Orthopaedics 10 (4.5) 9 (90.0) 1 (10.0) 1.256 0.321 0.458* 0.040− 2.593
159 (74.3) 55 (25.7)
Radiology 16 (7.1) 13 (81.3) 3 (18.8) 0.359 0.675 0.766* 0.185− 2.460
155(74.5) 53 (25.5)
Anaesthesia 28 (12.5) 14 (50.0) 14 (50.0) 10.667 3.667 0.001 1.622− 8.289
154 (78.6) 42 (21.4)
ENT 16 (7.1) 15 (93.8) 1 (6.3) 3.231 0.185 0.079* 0.024− 1.437
153 (73.6) 55 (26.4)
O&G 18 (8.0) 12 (66.7) 6 (33.3) 0.725 1.560 0.395 0.557− 4.372
156 (75.7) 50 (24.3)
Current Year in Masters
First 41(18.3) 34 (82.9) 7 (17.1) 0.563 1.776 0.195 0.234− 1.353
134 (73.2) 49 (26.8)
Second 33 (14.7) 22 (66.7) 11 (33.3) 1.433 1.622 0.231 0.731− 3.600
146 (76.4) 45 (23.6)
Third 70 (31.3) 50 (71.4) 20 (28.6) 0.693 1.311 0.405 0.692− 2.484
118 (76.6) 36 (23.4)
Fourth 80 (35.7) 62 (77.5) 18 (22.5) 0.415 0.810 0.520 0.426− 1.540
106 (73.6) 38 (26.4)
Average Hours Worked Per Week (56.44±15.42) 10.439 2.769 0.001 1.476− 5.197
120
Below 56 100 (83.3) 20 (16.7)
(54.3)
101
56 and more 65 (64.4) 36 (35.6)
(45.7)
Time Taken to Travel to work place/day (minutes)
0.006 1.025 0.938 0.554− 1.894
(33.55±22.63)
131
Below 34 98 (74.8) 33 (25.2)
(58.5)
34 and more 93 (41.5) 70 (75.3) 23 (24.7)
Average Number of Missed Meals due to Work/
5.191 2.044 0.023 1.099− 3.804
week (3.15±2.41)
113
Below 3 92 (81.4) 21 (18.6)
(50.7)
110
3 and more 75 (68.2) 35 (31.8)
(49.3)
Oncalls/Night Shifts per month (3.55±1.69) 1.720 0.666 0.190 0.362− 1.225
113
Below 4 89 (78.8) 24 (21.2)
(50.4)
111
4 and more 79 (71.2) 32 (28.8)
(49.6)
Relief from Duty After a Night Shift/Oncall 3.107 1.744 0.78 0.936− 3.248
Yes 79 (35.6) 54 (68.4) 25 (31.6)
143
No 113 (79.0) 30 (21.0)
(64.4)
(continued on next page)

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N. Nair et al. Asian Journal of Psychiatry 56 (2021) 102548

Table 1 (continued )
PHQ score less than PHQ score 10 and X2 Odds P value 95 % Confidence
10 (n%) above (n%) Ratio interval

Deaths of Patients per Month (1.63±2.69) 2.982 0.569 0.084 0.298− 1.083
Below 2 145 114 (78.6) 31 (21.4)
(68.1)
2 and more 68 (31.9) 46 (67.6) 22 (32.4)
Average Hours of Protected Study Time per Week 10.796 0.286 0.001 0.131− 0.622
(3.82±6.22)
Below 4 147 100 (68.0) 47 (32.0)
(65.9)
4 and more 76 (34.1) 67 (88.2) 9 (11.8)
Average Hours of Lectures/CME per week (2.68 9.685 0.350 0.002 0.178− 0.688
±1.94)
Below 3 127 85 (66.9) 42 (33.1)
(57.2)
3 and more 95 (42.8) 81 (85.3) 14 (14.7)
Average Hours Dedicated to Leisure/Hobbies per 4.349 0.482 0.037 0.241− 0.965
Week (5.22±7.43)
less than 5 145 102 (70.3) 43 (29.7)
(65.3)
5 and more 77 (34.7) 64 (83.1) 13 (16.9)
Average Hours Dedicated to Exercise per Week 4.137 0.510 0.042 0.264− 0.982
(1.87±2.79)
less than 2 133 93 (69.9) 40 (30.1)
(59.9)
2 and more 89 (40.1) 73 (82.0) 16 (18.0)
Average Hours of Sleep per week (41.74±7.90) 1.763 0.660 0.184 0.356- 1.221
less than 42 83 (37.2) 58 (69.9) 25 (30.1)
More than 42 140 109 (77.9) 31 (22.1)
(62.8)

associations with depression were longer working hours (p-value: 0.001,

Table 3
OR: 2.769) and missing meals at work (p-value:0.023, OR: 2.044).
Logistic Regression of Depression and Department of Anaesthesia.
Protected study time (p-value: 0.001, OR: 0.286), having CMEs/lectures
(p-value: 0.002, OR: 0.350), leisure or hobby time (p-value: 0.037, 95 % C.I.for EXP
P Adjusted (B)
OR:0.482) and exercise (p-value: 0.042, OR: 0.510) were all signifi­ B S.E.
Value Odds Ratio
cantly associated with lower rates of depression. Lower Upper
Logistic regression was done according to each of the departments Department of .789 .460 .087 0.454 0.184 1.120
which was significantly associated with depression. For the Department Anaesthesia
of Surgery (Table 2), the significant factor associated with depression is Working Hours − .696 .360 .053 2.006 0.991 4.064
Missed meals − .426 .357 .233 1.531 0.761 3.079
working 56 h or more per week (adjusted OR: 2.059, CI:1.015− 4.178),
Protected Study .911 .432 .035 0.402 0.172 0.937
as well as protected study time a week (adjusted OR:0.363, CI: Hours
0.158− 0.833). However, in the Department of Anaesthesia (Table 3), CME/Lectures .513 .386 .183 0.599 0.281 1.275
only protected study time was found to be a significant factor (Adjusted Leisure/hobby .155 .406 .703 0.857 0.387 1.897
OR: 0.402, CI:0.172− 0.937). Protected study time was also found to be a Exercise .468 .372 .209 0.626 0.302 1.299

significant factor in the low rates of depression in the Department of Nagelkerke R Square: 0.200.
Rehabilitation Medicine (adjusted OR: 0.319, CI:0.138− 0.737)
(Table 4).
Table 4
4. Discussion Logistic Regression and Department of Rehabiliation Medicine.
95 % C.I.for EXP
P- Adjusted
Depression is known to be underdiagnosed and undertreated B S.E. (B)
value Odds Ratio
worldwide (Sheehan, 2004) and this holds particularly true for this Lower Upper

Rehabilitation − 1.735 1.079 .108 5.667 0.684 46.940

Medicine
Table 2
Working Hours − .555 .360 .123 1.741 0.860 3.525
Logistic Regression of Depression and Department of Surgery. Missed meals − .330 .354 .352 1.391 0.695 2.786
95 % C.I.for EXP Protected Study 1.143 .428 .007 0.319 0.138 0.737
P Adjusted Odds (B) Hours
B S.E.
Value Ratio CME/Lectures .604 .374 .107 0.547 0.263 1.139
Lower Upper Leisure/hobby .104 .403 .797 0.902 0.409 1.988
Surgical − .037 .540 0.945 1.038 0.360 2.993 Exercise .479 .367 .192 0.619 0.302 1.271
Department
Nagelkerke R Square: 0.206.
Working Hours − .722 .361 0.045 2.059 1.015 4.178
Missed meals − .443 .361 0.220 1.557 0.767 3.159
Protected Study 1.014 .425 0.017 0.363 0.158 0.833 vulnerable population, the doctors. While the prevalence worldwide is
Hours estimated to be around 4.4 % according numbers by the World Health
CME/Lectures .688 .373 0.065 0.503 0.242 1.044
Organization, a meta-analyses done has estimated the prevalence of
Leisure/hobby .149 .404 0.712 0.861 0.391 1.900
Exercise .426 .365 0.243 0.653 0.320 1.336 depression among doctors to be 28.8 %, with a range of between 20.9 %
and 43.2 % in the studies analysed (Mata et al., 2015), which is far
Nagelkerke R Square: 0.183.

5
N. Nair et al.
higher than the prevalence in general population. In our study, the
prevalence of depressive symptoms was found to be 25.1 %, which
correspond to the range of depression found by Mata and colleagues in
their meta analyses among doctors. In Malaysia, there is a lack of studies
done among the general population of doctors. However, there are a few
studies done on more specific sub-populations of doctors. In a study
involving only medical officers from the Emergency Department, the
prevalence of depression was 10.7 % with no difference in age, gender,
marital status and, and number of shifts worked (Yahaya, 2018). In
another sub-population of doctors in Malaysia, the house offi­
cers/interns, the prevalence of depression was found to be 57.1 %, with
longer work experience being a protective factor (Fuad Fuad et al.,
2016).
In our study, there was a significant association between longer
working hours and depression. This finding has been replicated among
doctors in other countries as well, such as Portugal (Afonso et al., 2017),
France (Embriaco et al., 2012), and Turkey (Demir et al., 2007), albeit in
different subpopulations of doctors. Expanding to other professions, a
5-year longitudinal study done among British civil servants (Virtanen
et al., 2011) and a 3-year longitudinal study among Japanese clerical
workers (Amagasa and Nakayama, 2013) had also found a significant
association between depression and longer working hours. When
comparing working hours, our study had found that the mean working
time was 56 h per week, which exceeds the 48 h working week that a
recent study in United Kingdom suggested was optimal for the mental
health of an individual (Kamerāde et al., 2019). To reduce the number of
working hours among doctors in Malaysia, it may help by offering a
replacement off day or reduced working hours after an on call or a night
shift. It would also be helpful to better spread the work allocated better,
to ensure that all resident doctors are able to finish their work on time.
Another significant finding in our study was that spending time in
leisure or hobbies, was protective towards developing depression,
similar finding seen in another study in Turkey (Erdur et al., 2006). It is
interesting to note that developing hobbies is being used in the care
plans of patients with depression (Fancourt et al., 2020). This would
suggest that it may be useful to encourage doctors to develop methods of
leisure or hobbies to prevent depression. Exercise is another factor that
was found to be significantly associated in our study and there is evi­
dence that it does help to protect against developing future depression
(Harvey et al., 2018), as well as treating depression (Schuch et al.,
2016). It is also interesting to note that the organization of a Sports Day
has been shown to improve the mental health care among healthcare
providers in an addiction and mental health institution (Vuong et al.,
2020).
Missing meals was significantly associated with depression as well,
hence it would be essential to encourage doctors to have their meals
regularly. Furthermore, in a study done among students, performance
was found to be improved after meals were provided (Schwartz and
Rothbart, 2019). It would be interesting to see if a similar enhancement
of performance can be obtained by providing meals to doctors, espe­
cially so resident doctors as they are essentially students as well.
Furthermore, it is also important to remember that while resident doc­
tors are working, that their academic requirements are not neglected as
well, as seen by the two significant associations of protected study hours
and lectures with depression. This is a unique population, as there an
increased burden during these crucial years of their professional careers,
needing to juggle between work, personal life as well as studies. It is
important that this be recognised, and that adequate time be given for
their residents to study as well as prep for their exams. The imple­
mentation of study breaks, especially when exams are approaching
could help address this issue. Furthermore, structured lectures and
teaching should be implemented across all departments as not only does
it result in specialists who with good knowledge and skills, but also
possibly specialists who are not depressed.
However, there were results that were conflicting with previous
studies as well. A well-documented finding in studies among doctors was
6
Asian Journal of Psychiatry 56 (2021) 102548
that being females were significantly associated with depressive symp­
toms (Demir et al., 2007)(Naheed et al., 2012)(Erdur et al., 2006)(Gupta
et al., 2020), which was attributed to concerns about work-life balance
(Guille et al., 2017). However, in our study, sex was not significantly
associated with higher levels of depressive symptoms as there could be
poor work life balance among both sexes in this particular population,
due to the demands of post graduate training. Another significant factor
that was found in other studies (Su et al., 2009)(Whitley et al., 1994) but
which was not reflected in our study was marital status. While the
reasons for this appears unclear as social support does protect against
depression, a high percentage of resident doctors were married to doc­
tors themselves, who could possibly be burdened by symptoms of
depression, burnout and stress, leading to a lack of support.
In summary, depression among resident doctors is a legitimate
concern, with multiple significant association covering different aspects
of their lives and steps need to be taken to help improve their mental
health, as this would lead to a more productive, effective and happier
generation of future specialists in the healthcare of Malaysia.
Contributors
All authors were involved in the study involved. Navin Nair collected
the data and wrote the first draft, with inputs from Ahmad Hatim
Sulaiman and Chong Guan Ng. Navin Nair and Chong Guan Ng were
involved in the data analysis. All authors contributed significantly and
agree with the contents of the manuscript.
Funding source
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Declaration of Competing Interest
None of the above authors have any conflicts of interest to report
Acknowledgements
The content is solely the responsibility of the authors and do not
necessarily reflect the official view of University Malaya Medical Centre.
The authors would like to thank the resident doctors who participated in
this research, and the head of departments for giving consent for the
participation of their residents in this research.
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