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Research Article - ASEAN Journal of Psychiatry (2021)

FACTORS ASSOCIATED WITH STRESS AND DEPRESSION AMONG FAMILY MEDICINE RESIDENTS IN AL MADINAH, SAUDI ARABIA

1Joint Program of Preventive Medicine Post Graduate Studies, Al-Madinah 41311, Saudi Arabia
2Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
3Family and Community Medicine Department, College of Medicine, Taibah University, Al-Madinah, Saudi Arabia

*Corresponding Author:

Sami Abdo Radman Al-Dubai, Joint Program of Preventive Medicine Post Graduate Studies, Al-Madinah 41311, Saudi Arabia, Email: samidobaie@yahoo.com

Received: 22-Jun-2021 Published: 04-Aug-2021

Abstract

Stress and depression among physicians are recognized as important problems because of the potential risks they impose on individual health and medical care. This study aims to assess level of stress and depression and associated factors among family medicine residents in Al-Madinah, Saudi Arabia. Methods: This cross-sectional study was conducted among 75 residents in the family medicine residency programs in Al-Madinah. Stress and depression were assessed by using the stress and depression subscales of the validated Depression, Anxiety and Stress Scale-21 item (DASS-21). Sources of stress were assessed by 22 items. Results: Most participants had stress (57.3%) and depression (53.3%). Stress was associated with work overload (P=0.032), work demands affect personal/home life (P<0.001), inability to participate in decision making (P=0.026) and inability to make full use of skills and abilities (P=0.019). Depression was associated with ‘work demands affect personal/home life’ (P<0.001). Conclusion: The prevalence of stress and depression among family resident doctors was high. Establishing a residency counseling office is suggested to deal with the resident's problems in a way that supports their needs and leads to the best working environment.

Keywords

Depression, Family Medicine, Physicians, Residents, Stress

Introduction

Studies have suggested that resident physicians experienced high rates of stress and depression [1]. This is so because of increased expectations and responsibilities and the fact that residents are expected to be proficient clinicians, educators, researchers and administrators at the end of their training. Beyond the effects of depression on individual’s health, resident depression has been linked to poor-quality patient care and increased medical errors [2]. Estimates of the prevalence of depression was reported to be up to 60% [3]. Stress had been linked with musculoskeletal disorders, high blood pressure, disturbed metabolism, cardiovascular problems, mental health problems and premature mortality [4]. Physicians are exposed to many stressors, such as the burden imposed by expectations of a high degree of professionalism, responsibility for patient well-being and maintenance of relationships with patients and health workers, as well as concerns about medical errors and malpractice litigation [5]. Such occupational stressors had been reported to be associated with depression and stress among residents [6]. This study aims to assess level of stress and depression and associated factors among family medicine residents in Al-Madinah, Saudi Arabia.

Material and Methods

This cross-sectional study is a part of bigger study [7]. All residents in the family medicine residency programs in Al-Madinah were asked to participate in this study (n=105). Participants were approached two months before exam to avoid the stressful examination period.

A self-administered questionnaire consisting of three parts was used in this study. The first part included questions on sociodemographic and work characteristics. The second part assessed stress and depression by using the stress and depression subscales of the validated Depression, Anxiety and Stress Scale-21 item (DASS-21). Stress subscale contains seven items and assesses difficulty relaxing, nervous arousal, and being easily upset/agitated, irritable/over-reactive and impatient [8]. Depression subscale contains seven items and measures hopelessness, low self-esteem and low positive affect. Each item is scored on a four-point Likert scale ranging from zero (Did not apply to me at all over the last week) to three (Applied to me very much, or most of the time over the past week). Total score of stress and depression were obtained by summing up the relevant questions of each subscale. Sources of stress were assessed by 22 items which were obtained from the literature. These items were headed by the following question: “to which extent dose the following conditions cause stress to you”. Each item was scored from zero (Causing no stress) to 4 (Causing severe stress).

Analysis was performed using Statistical Package for the Social Sciences (SPSS®) (version 22.0, IBM, Armonk, NY). Total score of stress and depression were multiplied by 2. Test of normality was performed for the total stress scale and depression scale. To check for the factorial structure validity of the Stress and Depression Scale, an exploratory factor analysis was performed using principal component method with varimax rotation. The analysis yielded two-factor structure. Cronbach’s alpha of stress scale and depression scale were 86% and 88%, respectively, which indicate satisfactory internal consistency. Total score of stress and depression were categorized to ‘normal’, ‘moderate’, ‘severe’ and ‘extremely severe’ according to the recommended cut-off scores [9]. To assess the association between the continuous and the categorical variables, we used t-test and ANOVA test. Correlation analysis was used to assess the association between the continuous variables. To obtain the significant factors associated with stress and depression, multiple linear regression analysis was employed by using “Backward” technique. Multi-collinearity was checked between the independent variables by using the VIF (Variation Inflation Factor). The accepted level of significance was set below 0.05 (p<0.05).

Ethical considerations

Ethical approval was obtained from the ethical committee of the Directorate of Health in Al-Madinah. Objectives and benefits of the study were explained to the participants. Participant’s confidentiality and anonymity were assured. Signed consent was obtained from the participants.

Results

Out of 105 residents, 75 completed the survey (71% response rate). Respondents and non-respondents were compared on available demographic variables and no significant differences were found.

Most respondents were female (45.3%), aged 28-30 years (84.0%) and singles (50.7%). Working in shift was reported by 28.0% of respondents. Most of the respondents were in their first year in study (33.3%) and had 1 to 2 years of experience since graduation (62.7%). Academic performance was reported as poor by 9.3%, good by 48.0%, very good by 36.0% and excellent by 6.7% of the respondents (Table 1).

Table 1: Sociodemographic and Work Characteristics of the Respondents

N %
Gender
Male 34 45.3
Female 41 54.7
Age
25-27 10 13.3
28-30 60 86.7
Marital status
Single 38 50.7
Married 37 49.3
Working in shift
Yes 21 28.0
No 54 72.0
Academic year
1st 25 33.3
2nd 24 32.0
3rd 17 22.7
4th 9 12.0
Duration of work since graduation
1-2 47 62.7
3-4 18 24.0
5-6 10 13.3
Academic performance
Poor 7 9.3
Good 36 48.0
Very Good 27 36.0
Excellent 5 6.7

The five most important stressors ranked by residents were tests/examinations, large amount of content to be learnt, fear of making mistakes, work overload, time pressures and deadlines to meet (Table 2).

Table 2: Sources of Stress Ranked by the Mean

Sources of stress Mean
Tests/examinations 2.8
Large amount of content to be learnt 2.6
Fear of making mistakes 2.6
Work overload 2.4
Time pressures and deadlines to meet 2.3
Unfair assessment from superior 2.3
Work demands affect my personal/home life 2.2
Lack of time to review what have been learnt 2.2
Having to do work outside of my competence 2.1
Working with uncooperative colleagues 2.1
My work is mentally straining 2.0
My life is too centered on my work 2.0
Lack of support from superior 1.9
Having difficulty understanding the content 1.8
Unable to make full use of my skills and ability 1.8
My beliefs contradict with those of my superior 1.7
Lack of authority to carry out my job duties 1.7
Working with incompetence colleagues 1.7
Society does not think highly of my profession 1.6
Cannot participate in decision making 1.5
Difficulty in maintaining relationship with superior 1.5
Competition among colleagues 1.3

The mean (SD) stress score was 16.6 (9.4) and stress score ranged from zero to 42. About 46.7% of the residents had no stress, 16.0% had mild stress and 17.3% had moderate stress. Severe and extremely severe stress were reported by 14.7 % and 5.3% respectively. The mean (SD) depression score was 12.9 (9.8) and depression score ranged from zero to 42. About 42.7% of residents had no depression, 20.0% had mild depression, and 14.7% had moderate depression. Severe and extremely severe depression was reported by 10.0% and 12.0% respectively (Table 3).

Table 3: Levels of Stress and Depression

Stress Depression
n % n %
Normal 35 46.7 32 42.7
Mild 12 16.0 15 20.0
Moderate 13 17.3 11 14.7
Severe 11 14.7 8 10.7
Extremely severe 4 5.3 9 12.0

Participants who were working in shift had significantly higher stress compared to those who were not (P=0.013) (Table 4).

Table 4: Association of Stress and Depression with Sociodemographic and Work Characteristics

Stress Depression
Mean SD P value Mean SD P value
Gender
Male 16.2 10 12.7 9.8
Female 17 9 0.719 13.1 9.9 0.857
Age
25-27 19.4 13.6 17.2 12.04
28-30 16.2 8.6 0.317 12.2 9.39 0.306
Marital status 0
Single 16.2 9.4 14.42 11.07
Married 17.2 9.4 0.632 11.40 8.25 0.186
Working in shift
Yes 20.8 8.6 13.5 8.500
No 15 9.2 0.013 12.5 10.07 0.489
Academic year
1st 16 7.8 11.60 7.5
2nd 17.2 10.8 13.41 11.25
3rd 15.8 11.2 14.23 12.58
4th 18 6.8 0.919 12.88 5.7 0.851
Duration of work since graduation
1-2 16.2 8.8 12.7 9.4
3-4 19 10.4 15.1 11.7
5-6 14.2 10.6 0.390 10 7.7 0.414
Academic performance
Poor 19.2 5.2 25 4.2
Good 17.4 9.6 13.1 9.9
Very good 14.8 8.6 11.1 7.9
Excellent 17.2 16.2 0.656 19.2 17.4 0.130

Stress was correlated positively and significantly with all sources of stress in this study. Correlation coefficient ranged from 0.23 (weak correlation) to 0.65 (moderate correlation) (Table 5). Depression was correlated positively and significantly with 8 out of 22 sources of stress. The highest correlation was with the item ‘work demands affect my personal/home life’ (r=0.50, P<0.001) (Table 5).

Table 5: Association of Stress and Depression with Sources of Stress

Stress Depression
Sources of stress Correlation coefficient (r) Pvalue Correlation coefficient (r) P value
Tests/examinations 0.37 0.001 0.040 0.732
Large amount of content to be learnt 0.35 0.002 0.165 0.156
Time pressures and deadlines to meet 0.33 0.004 0.161 0.168
Having to do work outside of my competence 0.45 <0.001 0.333 0.004
Work overload 0.44 <0.001 0.172 0.144
Unfair assessment from superior 0.42 <0.001 0.285 0.013
Fear of making mistakes 0.30 0.010 0.104 0.376
My work is mentally straining 0.52 <0.001 0.339 0.003
Work demands affect my personal/home life 0.66 <0.001 0.500 <0.001
Lack of time to review what have been learnt 0.38 0.001 0.089 0.445
Having difficulty understanding the content 0.28 0.016 0.079 0.502
Working with uncooperative colleagues 0.24 0.040 0.102 0.384
My beliefs contradict with those of my superior 0.28 0.014 0.163 0.162
Cannot participate in decision making 0.37 0.001 0.325 0.004
Unable to make full use of my skills and ability 0.27 0.022 0.234 0.044
My life is too centered on my work 0.41 <0.001 0.278 0.016
Lack of support from superior 0.35 0.002 0.087 0.455
Lack of authority to carry out my job duties 0.35 0.002 0.166 0.155
Working with incompetence colleagues 0.25 0.028 0.141 0.229
Competition among colleagues 0.30 0.010 0.224 0.053
Difficulty in maintaining relationship with superior 0.23  0.047 0.212 0.068
Society does not think highly of my profession 0.28 0.014 0.248 0.032

(Table 6) exhibits the predictors of stress and depression among family medicine residents in multivariate analysis. The significant predictors of stress in the final model were work overload (P=0.032), work demands affect personal/home life (P<0.001), inability to participate in decision making (P=0.026) and inability to make full use of skills and abilities (P=0.019). The total model was significant (P<0.001) and explained 46% of the variance of stress score. There was no multi-collinearity between independent variables, given that the variation inflation factor (VIF) values were less than 10.

Table 6: Factors Associated with Stress and Depression in Multivariate Analysis

B SE Beta 95%CI p
Factors associated with stress
Work overload 1.0 0.5 0.23 0.09 1.94 0.032
Work demands affect personal/home life 2.3 0.5 0.57 1.40 3.21 <0.01
Inability to participate in decision making 1.1 0.4 0.26 0.14 2.05 0.026
Inability to make full use of skills and abilities 1.4 0.6 0.30 0.23 2.47 0.019
Factors associated with depression
Work demands affect personal/home life 3.8 0.9 0.45 2.02 5.53 <0.01

Regarding depression score, the only significant predictor was ‘Work demands affect personal/home life’ (P<0.001). The total model was significant (P<0.001) and explained 19% of the variance of depression score.

Discussion

In this study, 53.3% residents had stress. A previous study in Saudi Arabia (2015) found that the prevalence of stress among family medicine residents was 63.2%. The prevalence of stress in the previous international studies ranged from 17.7% to 42% [10-13]. The higher prevalence found in the current study could be related to the differences in working environment, cultural difference, sources of stress, and the health system. Also, the difference between different residence programs could affect the level of stress among residents. Our study showed that stress was correlated positively and significantly with all sources of stress (22 sources). In the previous studies, sources of stress were associated significantly with stress and burnout among residents and medical students. The most-reported stressors include work environment, work overload, academic stressors, tests and examinations, lack of family support, financial difficulties, relationships with trainers and colleagues, unclear long-term career future, long working hours, time pressures, excessive assignments and fear of making mistakes [14-19].

In this study, stress was associated significantly with working in shift but not with socio-demographic characteristics. Similarly, working in shift was associated with stress in the previous studies [20, 21]. Depression among residents has been linked to a higher risk of future depressive episodes and greater long-term morbidity and may affect the long-term health of resident doctors. In this study, 57.3% of the participants exhibited depressive symptoms. The prevalence of depression among residents in the previous studies ranged from 19% to 43.2% [22]. A higher prevalence of depression was found in a previous study in Dubai (63.3%). Depression was correlated positively and significantly with 8 out of 22 sources of stress in this study. Anagnostopoulos F also demonstrated associations between residents' mental health and sources of stress [23].

This study is not without limitations. First, the study sample included residents from one center of family medicine resident program in Saudi Arabia. Second, using a cross-sectional study design precluded the detection of any causal association. Moreover, we cannot exclude the possibility of reporting bias from self-reported data. Finally, the sample size is relatively small although we had a good response rate. The small sample size may have reduced the power of the study to detect differences between groups.

Conclusions

The prevalence of stress and depression among family resident doctors in this study was 57.3% and 53.3% respectively. Sources of stress were significantly associated with stress and depression. Establishing a residency counseling office is suggested to deal with the resident's problems in a way that supports their needs and leads to the best working environment.

References

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