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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 34  |  Issue : 2  |  Page : 163-171

Depression, anxiety, and stress among resident doctors of a teaching hospital


Department of Psychiatry, B.J. Medical College and Civil Hospital, Ahmedabad, Gujarat, India

Date of Web Publication29-Jun-2018

Correspondence Address:
Dr. Minakshi Parikh
Department of Psychiatry, B.J. Medical College and Civil Hospital, Ahmedabad, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_72_17

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  Abstract 


Introduction: Higher studies in general and postgraduate medical studies in particular carry a lot of stress. Some of it must be accepted, but a lot of it is modifiable by pertinent personal, institutional and policy changes. Hence, as a basic prerequisite, we have tried to assess the level of depression, anxiety, and stress suffered by the resident doctors of a teaching hospital in urban Gujarat. We also tried to find the various correlates. Aims and Objectives: (1) To find the prevalence of depression, anxiety, and stress in resident doctors of a tertiary care teaching hospital. (2) To study demographic characteristics among residents and its correlates with depression, anxiety, and stress. (3) To study the correlation of postgraduate training-related factors and personal factors with depression, anxiety, and stress. Materials and Methods: After taking informed consent and explaining the procedure, self-report forms were distributed to all 520 resident doctors of our institute. It constituted of a sociodemographic datasheet and Depression, Anxiety, and Stress Scale (DASS)-42, having 14 questions each of depression, anxiety, and stress. The data from the returned completely filled 462 forms were entered in Microsoft Excel version 2007 and analyzed using Epi Info and Chi-square test. Results: Higher than average prevalence of depression (27.71%), anxiety (36.58%), and stress (24.24%) was found among the resident doctors. Furthermore, variables such as being junior, long duty hours, no job satisfaction, residents of clinical branches, not having any hobbies, and staying at hostel were significantly associated with higher scores on DASS. Conclusion: Postgraduate medical studies engender a lot of stress which can result in personal tragedies, poorer patient care, and overall loss to the society. If doable strategic changes are brought about, the scenario can be improved.

Keywords: Anxiety, depression, postgraduate residents, prevalence, stress


How to cite this article:
Dave S, Parikh M, Vankar G, Valipay SK. Depression, anxiety, and stress among resident doctors of a teaching hospital. Indian J Soc Psychiatry 2018;34:163-71

How to cite this URL:
Dave S, Parikh M, Vankar G, Valipay SK. Depression, anxiety, and stress among resident doctors of a teaching hospital. Indian J Soc Psychiatry [serial online] 2018 [cited 2020 Sep 29];34:163-71. Available from: http://www.indjsp.org/text.asp?2018/34/2/163/235666




  Introduction Top


Medical training has been reported as being stressful.[1] The residency training is particularly more stressful because of increased expectations and responsibilities. The residents are expected to fulfill multiple roles – clinicians, educators, researchers, and administrators on completion of their training.[2] Long working hours, heavy workload, and relatively low control over the job contribute to stress resulting in depression, anxiety, fatigue, irritability, substance abuse, and sleep deprivation.

Resident doctors who study or practice medicine in developing countries like India encounter additional challenges including shortage of health sector budget, low income, and disparities in health-care distribution. Moreover, the need to study and work simultaneously make them more susceptible to psychological problems such as depression.

Studies conducted among medical students and residents revealed variable prevalence rates for depression ranging from 2% to 35%; with the higher rates among residents. Depression in physicians not only affects their own personal and family lives but also may have a serious impact on health behavior of the community in general. It may seriously affect residents' professional function.

Considering the enormity of depression in studies among resident doctors both in developed and developing countries, we conducted a study of the prevalence of depression, anxiety, and stress among resident doctors among resident doctors of a tertiary care teaching hospital in Ahmedabad, India.

It is usually considered that the workload and the symptoms of depression, anxiety, and stress are more in residents of clinical branches than those in the nonclinical branches, and the surgical branches as compared to nonsurgical branches. Level of training and sociodemographic characteristics may also be important factors.

Aims and objectives

  1. To find the prevalence of depression, anxiety, and stress in resident doctors of a tertiary care teaching hospital
  2. To study demographic characteristics among residents and its correlates with depression, anxiety, and stress
  3. To study the correlation of postgraduate training-related factors and personal factors with depression, anxiety, and stress.



  Materials and Methods Top


It was a cross-sectional, noninterventional study at a tertiary care general hospital in Ahmedabad, conducted between January 2016 and June 2016.

Subject selection

All the resident doctors who were ready to give informed consent were included in the study. Those who did not give informed consent or who were not available due to their examinations and those who did not return their forms after more than 7 days of distribution were excluded from the study.

Methodology

This study was approved by the Institutional Ethics Committee. Participants were included in the study after taking informed consent and they were assured of confidentiality.

Around 520 forms were distributed among the resident doctors of the aforementioned tertiary care hospital and its sister institutes and about 488 were returned, and out of which, 26 were incompletely filled and the complete sample size calculated was 462 residents, which was slightly above our predecided target of 450 resident doctors.

Instruments

Semi-structured pro forma

A semi-structured pro forma containing sociodemographic data including the basic information such as age, sex, marital status, postgraduate branch, Kuppuswamy scale and also questions regarding personal factors such as hobbies, past or family history of psychiatric illness, duty hours, accommodation, and holiday availability was distributed to the participants.

Depression, Anxiety, and Stress Scale – a 42-item questionnaire including 14 questions each of depression, anxiety, and stress, distributed randomly in the questionnaire. It was first developed by researchers at the University of New South Wales. Each question has a four-point Likert scale with responses ranging from 0 to 3 where 0 stands for not applicable at all and 3 stands for most applicable. Each of the depression, anxiety, and stress items are divided into 5 subgroups on the basis of their symptom severity – normal, mild, moderate, severe, and extremely severe.[3]

Analysis

Statistical analysis was performed using Epi Info. Chi-square test was applied to examine association of depression, anxiety, and stress with demographic characteristics as well as postgraduate training-related factors and personal factors. P < 0.05 was considered to be statistically significant.


  Results Top


Prevalence of depression, anxiety, and stress

About 27.7% resident doctors had depression, 36.6% had anxiety, and 24.2% had stress. Depression and stress were more often mild to moderate and anxiety severity was higher [Table 1].
Table 1: Depression, anxiety, and stress levels in resident doctors

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Sociodemographic factors and depression, anxiety, and stress

Ninety-one percent of the study population were aged below 30 years, 54.3% were men, 36.1% were either married or committed, 53.9% had their school education in a language other than English, 65.8% lived in hostels, 41.1% enjoyed hobbies, 18.1% had already used a substance, only 4.5% reported that they had psychiatric disorder in the past, and 3.9% reported family history of psychiatric disorder. Being older than 30 years of age was significantly associated with higher levels of depression. Other demographic characteristics such as sex, marital status, and socioeconomic status were not associated with either depression or stress levels. As regard to anxiety level, secular trends were observed on almost all characteristics [Table 2]a,[Table 2]b,[Table 2]c,[Table 2]d.


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Postgraduate training-related factors and depression, anxiety, and stress

Depression was higher in the 2nd-year residents, though level of training was not significantly associated with depression. Those who worked for more than 12 h a day (0.006), those who were not satisfied with their job (P = 0.00), and those who perceived their department as strict had higher depression (P = 0.0086).

Anxiety was significantly higher among residents in clinical branches compared to nonclinical branches (P = 0.03), residents registered in diploma courses compared to degree courses (P = 0.02), and in residents working more than 12 h a day compared to those with less working hours (P = 0.00), in residents with no job satisfaction compared to those who were satisfied or neutral (P = 0.00), and also in those who considered their department environment strict compared to ones who considered it lenient or were neutral (P = 0.003).

As regard to stress, stress levels were significantly higher in the following: residents in degree courses (P = 0.005), residents with more than 12 daily working hours (P = 0.01), and ones with no job satisfaction (P = 0.00) [Table 3]a,[Table 3]b,[Table 3]c,[Table 3]d.


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Personal factors and depression, anxiety, and stress

Among personal factors, having no hobbies was found to be significantly associated with depression, anxiety, and stress.

Accommodation in hostel was also found to be significantly associated with high levels of stress.

Personal factors such as medium of instruction in school, own psychiatric illness or family history, and substance use were not significantly associated [Table 4]a,[Table 4]b,[Table 4]c,[Table 4]d.


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  Discussion Top


The prevalence of depression, anxiety, and stress

The prevalence of depression is significantly higher than that among the normal population of the same age grouped students in India, which is 18.5% as per a study by Sahoo et al.[4] This difference is probably due to the fact that resident doctors have a dual responsibility of a student as well as a skilled professional clinician.

The prevalence of depression was almost at par with a meta-analysis survey done by Mata et al.[5] spanning multiple countries, which had a prevalence of depression of 28.3% among medical and surgical residents. While Zaman et al.[6] showed a 21%, Demir et al.[7] in Istanbul shows 16.0%, and 17.3% by Gu et al.[8] Our results have this difference probably because of their smaller sample size (n = 53) and different scales used by them. The stress level was slightly less than that found in a similar study done in New Delhi by Saini et al.[9] which reported it to be 32.8%, Cohen and Patten [2] reported 34%, and Kasi et al.[10] reported 55%. This could possibly be due to the larger sample size and more number of colleges and hospitals covered by them. There are very few studies which measured the anxiety among the postgraduate resident doctors.

The prevalence of depression was significantly high among those who were 30 years or more of age. This difference was statistically significant. However, on comparing the anxiety and stress levels, we did not find a statistically significant difference, despite the difference being substantially high. This could be due to the fact that those resident doctors who are 30 years or older would usually be married and would have now decided to pursue their postgraduate studies, which will increase the burden on personal as well as professional life.

The levels of depression and anxiety were higher among males than among females. This probably could be due to the fact that males prefer the surgical branches more than the females. No significant difference in stress level among the genders was found just like a study by Jenny and Leslie.[11]

Socioeconomic status was not significantly associated with increased depression, anxiety, or stress. This could be because the stipend of all the residents is uniform and that almost equalizes the economic condition of the resident as an individual.

When relationship of level of training and stress was explored, we found that the prevalence of depression was the highest among the 2nd years followed by the 1st and then the 3rd-year residents. The year of training was not associated with level of anxiety and stress, the difference was not statistically significant; however, it should not be ignored as it was quite high. Junior residents were found to have more stress overall than seniors. Similar findings were also reported in other studies.[2],[12],[13] The probable reason could be unequal work distribution, and also the fact that most of the 2nd-year residents, during the period of January to June, are the registrars and are directly responsible for the daily patient care and the activities in the unit. They also have to teach the 1st years apart from managing the work and academics.

When we compared the same among clinical and nonclinical branches, we got a statistically significant difference in the level of anxiety, which was more among those residents working in the clinical branches as compared to those in the nonclinical branches. This could probably be due to the fact that they have to directly deal with a patient, his/her life, and his caretakers. The moral responsibility increases as its he/she who has to treat them. The prevalence of depression (clinical: 29.8%; nonclinical: 20.4%) and stress (clinical: 26.7%; nonclinical: 15.5%), and this difference was not statistically significant.

On comparing the surgical versus the nonsurgical branches, the difference in the prevalence of depression, anxiety, or stress was not statistically significant. However, the difference was noticeably high. This contradicted the findings by Thomas [14] The prevalence of depression, anxiety, and stress was higher in the residents of the surgical branches than those of the nonsurgical branches. The difference was of more than 10% in depressive symptoms. This could be because of the increased workload that the surgical residents have, of procedures, surgeries both routine and emergency.

On comparing the prevalence among degree and diploma candidates, we found that the depression, anxiety, and stress were significantly higher among the diploma candidates than among the degree candidates and the difference was statistically significant too. This difference could possibly be due to the increased workload among the diploma candidates as they have to take the maximum possible training in 2 years as compared to the degree candidates who have 3 years to do the same. This was not compared in any of the other similar studies we came across.

We also found that the prevalence of depression, anxiety, and stress was significantly high among the residents who worked for 12 or more hours/day as compared to those who worked for lesser than 12 h. This supports the findings of other similar studies like Thomas [14] and Veasey et al.[15] This maybe because those having longer duty hours got less time for rest, relaxation, and recreational activities.

Job satisfaction, emerged as a robust factor associated with depression, anxiety, and stress. Out of 96 participants who were not satisfied with their jobs, 60, 65, and 52 people were screened positive for depression, anxiety, and stress, respectively, and the difference was statistically significant for all three groups (P = 0.00).

Strict departmental environment also emerged as important factor associated with depression, anxiety, and stress. The stricter the working environment was perceived, the tougher it got for the resident doctors.

Those residents living in the hostel were reported to be having higher depressive, anxiety, and stress-related symptoms as compared to those who were nonhostelites and were living at home with their family. The difference in the stress level among hostelites and nonhostelites was statistically significant. Our findings vis-à-vis the higher occurrence of depression, anxiety and stress in hostelites vs non-hostelites suggest that the presence of a familial support system may be an important protective factor against depression, anxiety and stress.

In relation to association with hobbies, the data showed that not all of the resident doctors had hobbies. More than 58% of them did not take part in any extracurricular indoor or outdoor activities in the previous 6 months. Having a hobby was a possible protective factor for depression, anxiety, and stress.


  Conclusion Top


  • In this study, we have tried to assess the mental well-being or the lack thereof, of the medicos undergoing their postgraduate training. The fact that these resident doctors are doing two full-time jobs at a time (that of treating patients and of training themselves and their juniors to become specialists) is reflected in the significantly higher incidence of depression, anxiety, and stress that they experience, as compared to the general population
  • The factors associated with higher degree of depression, anxiety, and stress among resident doctors are overwhelming duty hours, clinical specialties, migration from other areas of the countries, and lack of constructive coping strategies (like a hobby)
  • One other interesting finding of our study was that depression, anxiety, and stress experienced was highest among 2nd years followed by 1st years followed by 3rd years. This probably points toward our work distribution system which puts maximum clinical as well as teaching load on the 2nd years and the possibility that the 3rd years get used to the system and experience less depression, anxiety, and stress
  • Furthermore, the residents who perceived their departments as strict and felt less job satisfaction were at a higher risk for depression, anxiety, and stress. Finally, students doing diploma in a specialty reported more depression, anxiety, and stress, probably because the presence of imbibing more in less time as compared to the degree candidates
  • We suggest that a PG induction program at the start of the residency course, streamlining of the duties and rights of residents, and positive mental health training can go a long way toward reducing depression, anxiety, and stress among resident doctors, and thus improve their professional and personal well-being.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Joules N, Williams DM, Thompson AW. Depression in resident physicians: A systematic review. Open J Depress 2014;3:89-100.  Back to cited text no. 1
    
2.
Cohen JS, Patten S. Well-being in residency training: A survey examining resident physician satisfaction both within and outside of residency training and mental health in Alberta. BMC Med Educ 2005;5:21.  Back to cited text no. 2
[PUBMED]    
3.
Lovibond SH, Lovibond PF. Manual for Depression Anxiety and Stress scales. 2nd ed. Sydney : Psychology Foundation; 1995.  Back to cited text no. 3
    
4.
Sahoo S, Khess CR. Prevalence of depression, anxiety, and stress among young male adults in India: A dimensional and categorical diagnoses-based study. J Nerv Ment Dis 2010;198:901-4.  Back to cited text no. 4
[PUBMED]    
5.
Mata DA, Ramos MA, Bansal N, Khan R, Guille C, Di Angelantonio E, et al. Prevalence of depression and depressive symptoms among resident physicians: A Systematic review and meta-analysis. JAMA 2015;314:2373-83.  Back to cited text no. 5
[PUBMED]    
6.
Zaman S, Rahim MA, Khan AH, Habib SH, Rahman MM, Ahsan MS, et al. Prevalence of depression among post graduate medical trainees: A multi-centric Survey. Birdem Med J 2004;4:18-21.  Back to cited text no. 6
    
7.
Demir F, Ay P, Erbaş M, Ozdil M, Yaşar E. The prevalence of depression and its associated factors among resident doctors working in a training hospital in Istanbul. Turk Psikiyatri Derg 2007;18:31-7.  Back to cited text no. 7
    
8.
Gu A, Onyeama GM, Bakare MO, Igwe MN. Prevalence of depression among resident doctors in a teaching hospital. Int J Clin Psychiatry 2015;3:1-5.  Back to cited text no. 8
    
9.
Saini NK, Agrawal S, Bhasin SK, Bhatia MS, Sharma AK. Prevalence of stress among resident doctors working in medical colleges of Delhi. Indian J Public Health 2010;54:219-23.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Kasi PM, Khawar T, Khan FH, Kiani JG, Khan UZ, Khan HM, et al. Studying the association between postgraduate trainees' work hours, stress and the use of maladaptive coping strategies. J Ayub Med Coll Abbottabad 2007;19:37-41.  Back to cited text no. 10
    
11.
Jenny FC, Leslie AM. Sources of stress and ways of coping in junior house officers. Stress Med 1988;5:121-6.  Back to cited text no. 11
    
12.
Reuben DB. Depressive symptoms in medical house officers. Effects of level of training and work rotation. Arch Intern Med 1985;145:286-8.  Back to cited text no. 12
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13.
Garg G. Postgraduate lifestyle: Stress and satisfaction. Indian J Pediatr 2005;72:991.  Back to cited text no. 13
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14.
Thomas NK. Resident burnout. JAMA 2004;292:2880-9.  Back to cited text no. 14
[PUBMED]    
15.
Veasey S, Rosen R, Barzansky B, Rosen I, Owens J. Sleep loss and fatigue in residency training: A reappraisal. JAMA 2002;288:1116-24.  Back to cited text no. 15
[PUBMED]    



 
 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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