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

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
By Quyen Dinh Do

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.)

THESIS COMMITTEE

……………………………………………….Chairperson
(Prathurng Hongsranagon, Ph.D.)


……………………………………………… Thesis Advisor
(Associate Professor Prida Tasanapradit, M.D., M.Sc)


……………………………………………… External Member
(Rasmon Kalayasiri,M.D.)


iii
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
PHARMACY AT HOCHIMINH CITY, VIETNAM. THESIS ADVISOR:
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
Academic year 2007 Advisor’s signature

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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.


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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


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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


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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




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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 problem
s 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


ix
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


x

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


xi

ABBREVIATIONS
B
CES-D
C.I
df
HCM
SD
WHO
χ
2

: Regression coefficient
: The Center for Epidemiologic Studies Depression Scale
: Confident interval
: degree of freedom
: HoChiMinh
: Standard Deviation
: The World Health Organization
: Chi-square



CHAPTER Ι
INTRODUCTION
1.1 Background
Depressive disorders, causing a very high rate of diseases' burden, are
expected to show a rising trend during the coming 20 years. It is a significant public
health problem with relatively common, high prevalence and its recurrent nature
profoundly disrupts patients' lives. General population surveys conducted in many
parts of the world, including some South-East Asian Region countries, constituting 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


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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


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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.


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1.4.2 Specific objectives
− To assess the prevalence of depression among the first year Medical
students by using the Center for Epidemiologic studies depression scale.
− To determine the sources of stress among the first year medical
students.
− To find out the relationship between the main sources of stress, the
individual characteristics, potential personal consequences and depression.
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


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− Intrapersonal factors
− Academic factors
− Environment factors
Dependent variable
Depression
1.6 Operational definition
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


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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.


7
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.


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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
DEPRESSION
General characteristics
Age
Gender
Ethnic
Living status
Practice of religion
Perception of financial status
Coping with problem
Student stress
Interpersonal factors
Intrapersonal factors
Academic factors
Environment factors
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)


10
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).


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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


12
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


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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).


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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).