Open Journal Systems

ORIGINAL CONTRIBUTIONS

Received: March 13^th 2014
Accepted: November 7^th 2014

Depression, anxiety and suicide risk symptoms among medical residents over an academic year

José Luis Jiménez-López,^a Jesús Arenas-Osuna,^b Ulises Angeles-Garay^c

^aDepartamento de Psiquiatría y Psicología

^bDivisión de Educación en Salud

^cDivisión de Epidemiología Hospitalaria

Hospital de Especialidades, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Distrito Federal, México

Communication with: José Luis Jiménez-López
Telephone: (55) 5724 5900, extension 24058
Email: jimenezpsi@hotmail.com

Background: One of the causes of dissatisfaction among residents is related to burnout syndrome, stress and depression. The aim of this study is to describe the prevalence of depression, anxiety and suicide risk symptoms and its correlation with mental disorders among medical residents over an academic year.

Methods: 108 medical residents registered to second year of medical residence answered the Beck Depression Inventory, the State-Trait Anxiety Inventory and the Suicide Risk Scale of Plutchik: at the entry, six months later and at the end of the academic year.

Results: Residents reported low depressive symptoms (3.7 %), low anxiety symptoms (38 %) and 1.9 % of suicide risk at the beginning of the academic year, which increased in second measurement to 22.2 % for depression, 56.5 % for anxiety and 7.4 % for suicide risk. The statistical analysis showed significant differences between the three measurements (p < 0.001). The prevalence of depressive disorder was 4.6 % and no anxiety disorder was diagnosed. Almost all of the residents with depressive disorder had personal history of depression. None reported the work or academic environment as a trigger of the disorder. There was no association by specialty, sex or civil status.

Conclusions: The residents that are susceptible to depression must be detected in order to receive timely attention if they develop depressive disorder.

Keywords: Depression; Anxiety; Suicide; Medical residency

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It has been reported that a source of dissatisfaction for medical residents is related to environmental conditions, such as the excessive demand for care inherent in working in a public health institution, and performing activities deemed unsuitable for their status as doctors in training (messenger, orderly, secretary, etc.).^1-3 This dissatisfaction is referred in several ways: stress, burnout, depression, anxiety, mental exhaustion, and dissatisfaction.^4-7 Of these manifestations, depression and anxiety stand out as important, as they deserve treatment if they are part of a mental disorder, regardless of whether they are triggered by severe stress in the training environment. By definition, these mental disorders cause clinically significant distress or impairment in social or occupational functioning, or in other important areas of the subject’s functioning.⁸ It has also been reported that these changes lead to errors in medical duties⁹ and desire leave the residence (they are even identified as causes of attrition).^10,11

It is estimated that the global prevalence of depression is 5.8% in men and 9.5% women;¹² and in Mexico, 2.5% for men and 5.8% for women.¹³ In the case of anxiety, prevalence at international and national levels are 16% and 8.1%, respectively.^13,14

Prevalence of depression and anxiety in resident physicians has wide reported ranges probably because these conditions are usually measured transversely with scales that are not diagnostic, and without the presence of pathology being confirmed by structured psychiatric interview.¹⁵ Reports from highly specialized medical units (unidades médicas de alta especialidad, UMAE) at IMSS range from 25% to 79.6% for depression and 39% to 69.9% for anxiety,^6,16 with a higher prevalence of depression among second year residents.¹⁷ Other national and international studies report depression prevalences at 47.5% and 20%, respectively.^9,18

The literature on depression in medical professionals is plentiful but less so for suicide, although it is the most serious complication of psychiatric disorders. Over 50% of people who commit suicide were suffering from a depressive disorder; anxiety and alcohol abuse or dependence are found to a lesser extent. When there is comorbidity of these disorders, the risk for suicide or attempted suicide increases.^19,20 Moreover, it is also known that suicidal ideation is the best predictor of a suicide attempt, and repeated attempts, in turn, predict consummation.^21,22

Despite these findings, studies of suicidal ideation in doctors in training are scarce. The figures in medical students range from 1.4 to 32.3%;^23,24 in residents, the prevalence is more stable (around 12%).^25,26

Psychosocial changes in a short period of time have been associated with increased suicide rates in recent decades, because the uncertainty that is generated becomes a potential source of stress and vulnerability for a depressive or anxiety disorder in predisposed individuals.²⁷

The aim of this study was to measure symptoms of depression, anxiety, and suicide risk in medical residents at different times of the academic year. In making this measurement, we hoped to find increases in intermediate steps that indirectly confirm what is reported in other studies of the distress associated with the activity inherent to the training process (demand for care, academic demands, etc.). We also looked for correspondence between these symptoms and the presence of pathology, besides correlation between depression, anxiety, and suicide risk. We included a qualitative analysis in residents with mental disorders to explore the association with psychosocial factors.

Methods

A study of prevalence of symptoms of depression, anxiety, and suicide risk was carried out. We included medical specialty residents who began their second year of training (first at Hospital de Especialidades del Centro Médico La Raza). As part of their administrative procedures before starting the school year, they were asked to complete a form of sociodemographic information and measurement scales. Sociodemographic data requested were: age, sex, marital status, specialty, and family and personal psychiatric history. Measuring instruments applied were:

The Beck Depression Inventory:^28,29 a self-reported scale to measure depression, which has been adapted and validated in Spanish, and is free to use. There are three versions (42, 21, and 13 items); the abbreviated version was used to allow quick application and scoring, and because it has proposed cutoff points for severity of depressive symptoms (0-4 = absent, 5-7 = mild, 8-15 = moderate, > 15 = severe), unlike other versions, where there are no cut-off points.

The state-trait anxiety inventory:^30,31 designed to assess anxiety as a state (transient emotional condition, 20 items) and anxiety as a trait (relatively stable anxious propensity, 20 items). It is self-administered. In our case, we only used the state anxiety subscale for the characteristic of transience. The scores are ranked as follows: 20-31 = minimal anxiety; 32-43 = low anxiety; 44-55 = average anxiety; 56-67 = high anxiety; 68-80 = very high anxiety.

The Plutchik suicide risk scale:³² a scale designed to assess suicide risk. It is self-administered. It is adapted and validated to the Spanish, and is free to use. A cutoff of 6 is proposed.

We preferred to assess suicide risk and not exclusively suicidal ideation, because the scale used includes questions about previous suicide attempts, the current intensity of ideation, feelings of depression and hopelessness, and other aspects related to attempts, which allows a full assessment in case intervention is required.

These scales were applied again at the middle and end of the academic year. All residents signed a letter of informed consent for their participation in the research.

Interviews were also conducted with those who went for psychiatric/psychological assessment, whether spontaneously or at our request due to high scores on the scales. During the consultation, issues of academic performance, interpersonal relationships, and the workplace and its association with the emotional state were discussed. They were asked to respond to the scales again. In addition, there was a list of questions based on the Diagnostic and Statistical Manual of Mental Disorders (DSM IV)⁸ that standardized the interviews. The assessment was conducted by one of the researchers.

Results

One hundred and eight residents were studied, 35.19% were women. The specialties involved were General Surgery (37.04%), Anesthesiology (27.78%), Internal Medicine (27.78%), Pathology, and Urology. The most frequent marital status was single with 80.56%; personal history of depression was found in seven people and a family history in nine (Table I).

The average age of study subjects was 26.39 (with an SD of 1.78). When comparing scores and measures of symptoms of depression, anxiety, and suicide risk, the baseline average depression was 0.81, while the midpoint average was 2.99 (p <0.001); the baseline average anxiety score was 30.6, midpoint average 37.81, and endpoint average 31.84 (p <0.001). Finally, the suicide risk score at baseline was 0.69 and 1.70 at the midpoint measurement (p <0.001) (Table II).  At baseline depressive symptoms were absent in 96.3% of subjects studied, and at the final measurement, a year later, depression symptoms were absent in 88%, down to 70.4% in the midpoint measurement (p <0.001). On average anxiety symptoms were present at baseline in 3.7% of those studied; the percentage rose to 19.4% in the midpoint measurement, and at the final measurement they were present in 9.3% (p < 0.001). The symptoms of suicide risk were presented in 2% at baseline and 7.4% in the middle; in the final measurement none of the subjects studied had symptoms of suicide risk (p = 0.003) (Table III).

When looking for a relationship with personal history of depression, it was found that those who had had a history of depression had an odds ratio (OR) of 5.44 (95% CI 0.49-60.53, p = 0.125) to have symptoms of depression. This risk increased to 25 (95% 2.83-220.85, p < 0.001) after six months. OR of the personal history of depression for anxiety symptoms was 5.44 (95% CI 0.49-60.53, p = 0.125). After six months there was no increase. OR of history of depression for having suicidal symptoms was 12.13 (95% CI 2.37-62.12, p < 0.001 at six months follow-up) (Table IV).

An analysis was made of subjects who had no history of depression. When comparing scores and measures of symptoms of depression, anxiety, and suicide risk, the baseline average depression was 0.72, while the midpoint was 2.45 (p < 0.001); baseline anxiety average score was 30.28, midpoint 37.10, and endpoint 32.12 (p < 0.001); finally, the score for suicide risk was 0.49 at baseline and 1.36 at the midpoint measurement (p < 0.001) (Table V).

At baseline depressive symptoms were absent in 97.03 of the subjects studied and at the final measurement, a year later, depression symptoms were absent in 88% (p = 0.001). Baseline average anxiety symptoms were present in 2.97 of those studied; the percentage rose to 21.98 in the midpoint measurement, and they were present in 10.75 (p < 0.001) at final measurement. The symptoms of suicide risk were presented in 4.35 at the midpoint measurement, and at final measurement none of the subjects studied had symptoms of suicide risk (p = 0.014) (Table VI).

At both midpoint and final evaluations there were residents who did not respond to the scales because they happened to be in rotations outside the unit (less than 10% of the sample). No residents were excluded.

Eight residents attended psychiatric assessment, five spontaneously and three upon researchers’ request due to high scores on the suicide risk and depression scales. Four women were diagnosed with major depressive disorder with high risk of suicide, so they were sent to the psychiatric hospital to assess hospitalization; three were hospitalized (two with severe depression and one with moderate depression; they belonged to Internal Medicine and Pathology specialties, respectively), the other began treatment and outpatient surveillance (she presented mild depression). Of the three who were hospitalized, two (single) reported relationship breakups and one (married) marital conflict as a trigger for depression; all three had personal history of this disorder. The resident (single) who was not hospitalized presented absent depression, minimal anxiety, and lack of suicide risk at baseline assessments; she had personal history of depression and reported having suspended her antidepressant treatment at the start of the academic year.

A resident (male, unmarried) met clinical criteria for moderate depressive disorder without risk of suicide, so he began psychopharmacological treatment and outpatient follow-up. He did not identify a triggering psychological factor or personal history of depression.

Three residents (two females and one male) were not diagnosed with a mental disorder. They reported "stress because of workload"; their anxiety was rated high in the midpoint measurement.

Two of the [female] residents who were hospitalized presented suicide risk in baseline assessments without symptoms of depression. The other resident hospitalized had mild depression without suicide risk in the initial assessment, but extreme scores in the midpoint evaluations.

Discussion

The results allow us to infer a difference between the presence of manifestations of emotional distress (anxiety, depression) and the presence of psychopathology in itself (depressive disorder, anxiety disorder) from the fluctuation presented in the prevalence of depressive symptoms (3.7% -22.2% -5.6%) and anxiety (3.7% -26.8% -10.2%) over the course of the academic year, with final values similar to baseline values ​​after an increase in midpoint measurements. These data agree with those reported in cross-sectional studies in which a high prevalence of symptoms of anxiety and depression are observed; however, they contrast with those reported for mental disorder, because in this sample the prevalence was 4.6% for major depressive disorder (similar to that reported in the general population), without anxiety disorders being diagnosed. They also do not support the idea that stress or distress generated by the requirements inherent in the specialization create depressive and/or anxiety disorders, since the prevalence of depressive disorder remained constant throughout the year (only one resident presented their first depressive episode) and the high scores of anxiety and depression returned almost to the levels of baseline measurements without any psychological intervention. However, our results are consistent with reports on the development of mental disorders in predisposed individuals²⁷ (four out of five had a personal history of depression). Although the highest scores were given by residents with mental disorders, differences in fluctuations remained even when they were excluded from the analysis, suggesting that indeed the demands of their training generated emotional distress for them, but not to the point of producing a mental disorder³³ (probably with the exception of those who are vulnerable, although in qualitative analysis the residents attributed their mental disorder to psychosocial factors other than work/academic environment).

Statistical analysis for differences in symptoms of depression, anxiety, and suicide risk by specialty showed that residents of Pathology showed greater anxiety and suicide risk at the beginning and the middle of the academic year, and depression at the midpoint; Urology had higher baseline anxiety; and Internal Medicine had greater anxiety in the middle of the year. When residents with depressive disorders were excluded, the difference in anxiety remained for Pathology and Urology at the beginning of the year, and Internal Medicine at the midpoint. These data may suggest that residents of Urology and Pathology presented higher levels of distress, manifested by anxiety, and the rest of the specialties probably present it due to uncertainty or the specific predispositions of the services in this unit, and that the level of demand is greater for Internal Medicine.^34,35 This also confirms that it is more likely that the symptoms of depression and suicide risk are present in vulnerable people, since differences in these manifestations disappear when the carriers of depressive disorders are excluded, most of whom have positive personal history for this disorder.

In regard to suicide risk, the known correlation with depressive disorder is confirmed;19 four of five residents were diagnosed with depressive disorder and high suicide risk requiring hospitalization. This correlation remained positive when carriers of this disorder were excluded, although the scores for symptoms of depression and anxiety did not reach pathological levels; that is to say, with greater manifestations of depression and/or anxiety, there was increased risk of suicide. This aspect is of particular interest because it calls for monitoring even those subjects with low scores on the suicide risk and depression and/or anxiety scales. The higher frequency of depressive disorder in women and single people is also confirmed, and the absence of statistically significant differences by gender and marital status, when those experiencing depressive disorder are excluded, again confirms the presence of emotional distress in the absence of a disorder.

A weakness of the study is the use of self-report scales that, although we try to identify residents with suspected mental disorder, do not ensure the absence of a disorder. Some residents might avoid being identified as having a mental disorder because of prevailing stigma, even in the medical field. Research on this issue reports that for medical students, seeking help for depression would make them feel less intelligent,23 and that a third of doctors not seek regular care for their health.^36,37

The qualitative part of the study gives it strength by directly obtaining psychosocial factors associated with depressive disorder; the sociodemographics are consistent with those long known (more prevalent in women and single individuals); and in the clinical signs a trigger is identified, but it is not related to specific aspects of the residency, and it is possible to detect individuals with vulnerability to depression, in addition to the correlation between depression and suicide risk, already mentioned.

Of particular interest to programs aimed at suicide prevention is addressing the phenomenon as a process, which begins with thoughts about how to end one’s life (ideas, desires), continues with suicidal behavior (attempts), and ends with suicide consummated.³⁸ Studies in Mexico have found that the presence of a mental disorder increased approximately five times the likelihood of suicidal ideation, and about 10 times the occurrence of a plan or an attempt to commit suicide.^21,22 Moreover, it has been observed that the age of first attempted suicide follows a double Gaussian distribution with one average of 19.5 + 4.3 years and another of 38.5 + 12.4 years, with a cutoff of 26 years for the two subgroups. In the subgroup of younger age anxiety is found more often, and in the older subgroup depression.³⁹ These data support the need for programs to promote mental health and prevent mental illness in medical residents.

Conclusions

The notion that pursuing a medical residency generates emotional distress is confirmed. However, it is not confirmed that such distress generates depressive or anxiety disorders and much less risk of suicide and no specialty is particularly identified as causing greater distress.

The results suggest the need to create strategies to detect depression early in the residence in order that vulnerable students receive timely care to enable them to continue their training. Moreover, they suggest the creation of programs that aim to soothe emotional distress in situations of higher pressure (workshops for stress management, motivation, improved self-esteem, etc.) and the prevention of mental illness.

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