Introduction
The pursuit of a career in medicine requires a high level of academic ability and dedication and perseverance. However, it is equally important that both medical schools and potential students recognise the psychological impact of the demands and challenges that students will encounter and the effect that this may have on their mental health as students and later as clinical practioners.
The process of becoming a physician is perceived as intense and challenging but also highly stressful. Studies have shown that medical students have higher rates of anxiety and depression than the general population (Dyrbye, Thomas &Shanafelt, 2005)(Baykan, Naçar&Çetinkaya, 2012). A meta-analysis showed that depression is thought to effect 28% of medical students globally(Puthran, Zhang, Tam & Ho, 2016). This has an impact not just on their time as a medical student but through to their training as a junior doctor Tempski et al., 2015. The effects of stress as a junior doctor has been demonstrated as a predictor of future mental health problems in future practice (Tyssen, Vaglum, Gronvold&Ekeberg, 2000).As well as a direct detrimental effect on academic performance (Stewart, Lam, Betson, Wong & Wong, 1999) continuing anxiety may cause a vicious cycle of self-doubt further impacting on academic performance (Bandura, 1993).
Studies have shown increased levels of alcohol and substance abuse in medical students (Said, Kypri& Bowman, 2012). Further the rates of suicide amongst medical students is also higher than the general population (Schernhammer, 2005).
It has been theorised that medical students may have a predisposition to depression which is greater than comparable populations but this has not been conclusively demonstrated with some studies finding slightly higher levels for depression in medical students, although below the cutoff point for depression(Buchman, Sallis, Criqui, Dimsdale& Kaplan, 1991). While others finding lower scores for depression compared to non-medical students(Hendryx, Haviland & Shaw, 1991)
The factors effecting higher levels depression may be due to the environmental pressures of medical school which have been described as being psychologically toxic(WOLF, 1994)(Tempski et al., 2012). The stressors can be bothacademicsuch as the volume and complexity of work, exam pressure and anxiety and Psychosocial stressors which may include high expectations from family to succeed, financial pressures and possibly living in a new area and being homesick(Fawzy&Hamed, 2017).
It has been suggested that there is a relationship between personality traits identified as a medical student and subsequent mental health after graduating and practicing as a junior doctor (Gramstad, Gjestad& Haver, 2013)
Spielbergers (1966) anxiety measure is based on two distinct forms of anxiety one is (A -State) which is a temporary state in response to a feeling of fear or trepidation whilst (A – Trait) is the predisposed behaviour (Endler, 1983). The aim of this study is to differentiate both state and trait anxiety in order to evaluate if there is a difference in their relationship to depression in medical students.
Method
Design
The design of this study was correlational. The relationship between both state anxiety and trait anxiety and depression was analysed using a multiple regression model. The dependent variable was depression and that was measured against two independent variables which were state anxiety and trait anxiety. With the aim to firstly establish if there was an association between both state and trait anxiety and depression and secondly quantify the extent of the relationship.
Participants
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A total of 1350 medical students completed the study. There were 103 participants with an age range between 18-25 (M = 21.84, SD =2.38, Mdn = 22.00). 52 male and 51 females. Participation in the study was voluntary with no financial inducements.Participants were medical students from 22 medical schools across Brazil.The means, standard deviation and number of participants are presented below in table 1. |
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Materials
The instrument used to measure depression was the Beck Depression Inventory (BDI) which has 21 questions with a range from 0-63 the higher the number indicating increased levels of depression (BECK 1961) retest reliability is>0.6 (Beck et al 1988). “Each item is scored from 0 to 3 to decide the participant’s level of depression. Those with total scores between 0 and 9 are not recognized as depressed, scores between 10 and 18 are indicative of mild to moderate depression, scores between 19 and 29 indicate moderate to severe depression, and scores between 30 and 63 are defined as severe depression”Levels of anxiety were measured using the State Trait Anxiety Inventory (STAI) (Spielberger 1980) which measures both strait and trait anxiety. Each component consists of 20 question which are on a Likart scale with 80 being the highest indicating high anxiety and 20 being the lowest indicating low anxiety.
High reliability was found on the TAI with a Cronbach’s Alpha reliability at = 0.871 (Spielberger 1980). The test-retest in Spielberger (1980) on high school, college and graduate level students over a 2-3 week period was r.80. Good internal consistency was reported by Spielberger (1980)with Cronbach alphas of .90 and .91 for males and females on the TAI-E .94 and .95 on the TAI-T and .88 and .90 on theTAI-W.The TAI has shown to be both reliable and valid, the values of 0.19–0.32 in discriminant validity for individuals with alpha values of 0.66–0.81 in reliability(Shabbir Ali, 2013).
Convergent validity is evidenced with the TAI subscales of worry and emotionality and other anxiety tests such as Liebert & Morris (WEQ). The high reliability and validity of both the TAI and the subscales has been proven with studies on both universities and school students (Spielberger& Gonzalez, 1980; Szafranski et al., 2012).
Procedure
Medical students from across Brazil were recruited and students were randomly selected from each medical school with an equal distribution of males and females, questionnaires were completed online which had to be completed within ten days or another student was randomly selected as a replacement. On completion of the questionnaires feedback was provided to the student as well as any support if required. Consent was obtained by electronic signature. The collection of the data was within a one year period from August 2011- August 2012. Participation in the study was voluntary and ethics was approved by the School of Medicine of the University of Sao Paulo and all of the medical schools that participated in the study.The data was analysed using SPSS
Results
The aim of this study was to identify if there was a relationship between state and trait anxiety on medical students level of depression A multiple regression was used to analyze if this was significant. A significant regression equation was found. In relation with analyzing the multiple regression of these variables it has been analyzed here that the significant value of this variables are 0.000 which is <0.05. Therefore, there will be alternative hypothesis will be followed. Moreover, in relation with the mean value of trait anxiety which is 45.49 while state anxiety has 43.66. Therefore, it can be said that in comparison with the state anxiety Trait anxiety’s mean value is comparatively more deviate. The R square of the variable is 0.494. In accordance with the beta value of the variables which is 0.703 that is <1 which ascertains that the there will be significant changes in the outcomes as it is not fluctuating and flexible. Therefore, it will not been changed in the coming time. Therefore, there has been impacts of various factors in the learning and analyzing the state and trait anxiety of depression. Moreover, this and psychological factors which impacts over the learning capacity of the medical students. Therefore, there will be influences of the environmental factors too which distract their capacity to learn and understand things. Thus, in relation with analyzing the reasons behind such anxiety there has been influence of the outcomes derived from regressions analysis. Similarly, below listed Scattered diagram will be helpful in making the adequate analysis on such observations.
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