The Prevalence of Depression , Anxiety , Stress and Its Association with Sleep Quality among Medical Students

Objectives: Currently, depression, anxiety, and stress among medical students are important health issues at global level. The aim of this study was to assess the prevalence of depression, anxiety, stress among medical students, and its association with socio-demographic characteristics and sleep quality. Materials and Methods: DASS-42 Scale and Richard Campbell Sleep Questionnaire were used to assess information on depression, anxiety, stress, and sleep quality. A total of 610 students (44.10% males and 55.90% females) with mean age of 20.90±2.10 years participated in the present study. Results: The overall prevalence of depression, anxiety, and stress were 60%, 66%, and 63% among all participated medical students, respectively. Depression level was high among students with poor economic level. Anxiety level was high among pre-clinical students with poor economic level, females and the ones whose choice of the medical faculties was not voluntarily. Stress level was higher in females. The correlation between sleep quality and depression, anxiety, stress was found statistically significant, negative, and low level. High depression, anxiety, and stress levels decreased students' sleep quality. Conclusion: An important proportion of medical students had high levels of depression, anxiety, and stress. Providing individual guidance and psychological counseling services for medical students could be beneficial.


Introduction
Currently, depression, anxiety and stress among medical students are an important health issues at the global level. Medical students must acquire sufficient vocational knowledge, skills, and attitudes to prepare themselves to cope with life-long professional difficulties. However, learning and educational demands can affect the physical and mental health of the students in a negative way. This situation leads to depression, anxiety, and stress in the life of medical students, and they tend to have more psychological distress compared to the general population. 1,2 Depression, anxiety, and stress formation among medical students can be multifactorial. These factors are classified as academic and non-academic (psychosocial and socio-demographic) stress factors. 3,4 These factors include comprehensive medical curriculum, long course hours, concerns about academic performance, high family expectations and socio-demographic characteristics. These stress factors may lead to depression, anxiety, stress, poor sleep quality, low academic performance, alcohol and drug abuse, loss of self-confidence, poor life quality, and psychiatric illnesses. [5][6][7][8] In a society, university students are the most dynamic element of society's sociocultural structure. It was stated that depression is the most important psychological distress that threatens this group in researches among university students. 9,10 Psychological distress prevalence (depression, anxiety, stress) among medical students has been varied in different studies and countries. The prevalence of depression has changed in various societies such as Sweden 12.90%; Iran 51%; Denmark 30.50%; Cameroon 65.2%. 8,11,12 Similarly, it is stated that the prevalence of anxiety in various societies (e.g. Pakistan 13%; Estonia 21.90%; Malesia 76.20% etc.) has changed between 13% and 76.20%. [13][14][15] The high prevalence of stress is one of the most important problems among medical students worldwide. For instance, different societies such as Nepal 27%; Malaysia 46.90%;Sudan 50,50%; Iran 72.30% indicated different stress levels. 4,6,7,11,16 Studies carried out in the medical faculty and other faculties in Turkey have showed that the prevalence of depression, anxiety and stress changed between 27.10%-73.50%; 17.90%-55.40%; 27%-46.40%; respectively. 5,[17][18][19][20][21][22][23] Many studies have reported that levels of depression, anxiety, and stress have been increased in recent years. Stress leads to some problems such as anxiety, depression, sleep disorders, coronary heart diseases, psychosomatic diseases, weakness of the immune system, and cancer. 6 In accordance with this information, the purpose of the present study was to investigate the prevalence of depression, anxiety, and stress among medical students in Afyonkarahisar Health Sciences University, and its association with socio-demographic characteristics and sleep quality. The hypotheses of study are given below: • What is the prevalence of depression, anxiety and stress among medical students at Afyonkarahisar Health Sciences University?
• Is there any association between socio-demographic characteristics and depression, anxiety, and stress?
• Is there a correlation between sleep quality and depression, anxiety, and stress?

Materials and Methods
The sample of the study consisted of a total of 610 (341 female and 269 male) medical students. A questionnaire form consisting of totally three parts was used in the study: A cross-sectional study was designed as a research method. Pearson correlation analysis was used to determine the relation between depression, anxiety, stress, and sleep quality. Independent sample t test was used to compare depression, anxiety, and stress level according to class (clinical class/pre-clinical class). Moreover, the important risk factors (socio-demographic characters and sleep quality) for depression, anxiety, and stress were determined using binary logistic regression analysis. SPSS software program was used for data analysis. The study was conducted in accordance with the ethical approval with the protocol number of 2017/11-261 from the Faculty of Medicine, Afyon Kocatepe University.
The difference between depression, anxiety, and stress levels according to the class of students was summarized in Table 2 and Figure 1. Anxiety level was statistically different according to the class of the students (p<0.05). Anxiety level in pre-clinical classes was higher than clinical classes. Depression and stress level were not statistically different according to the classes (p>0.05). As a result, depression and stress level did not change according to the class, and students had same depression and stress level (high level) in all classes (Table 2). Depression, anxiety, and stress levels of the students at second grade were higher than the other classes ( Figure 1).  Binary logistic regression analysis was used to evaluate the effects of sociodemographic characteristics of students on depression, anxiety, and stress. While the students with normal depression, anxiety, and stress were coded as "0", the students with slight, middle, high or very high depression, anxiety, and stress were coded as "1". The results of binary logistic regression analysis were shown in Table 3. The economic level of family, waking time in the morning, the use of energy substances (beverage, medicine, etc.), study duration during exam period, anxiety, and stress were identified as risk factors for depression. The middle economic level of family, the use of energy substances, and the length of study during exam periods reduced the risk of depression 1.80 times, 2.70 times, and 2.30 times, respectively. On the other hand, waking up after 7:00, anxiety, and stress increased the risk of depression 2.30 times, 3.90 times, and 7.80 times, respectively ( Table 3).
The economic level of the family, gender, education level of the father, smoking, voluntary or involuntary choice of the medical faculties, sleep quality, stress, and depression were identified as risk factors for anxiety. The good economic level of family, high education level of the father, and high sleep quality reduced the anxiety risk 2.10 times, average 2 times, and 1.50 times, respectively. On the other hand, being a woman, smoking, involuntary choice of the medical faculties, depression, and stress increased the anxiety risk 1.70 times, average 2 times, 1.80 times, 4.40 times, and 5.70 times, respectively (Table 3).
Gender, whether the father had a job, sleep quality, anxiety, and depression were identified as important risk factors for stress. Having a good sleep quality and having a working father reduced the stress risk 1.50 times, and 4.60 times, respectively. On the other hand, being a woman, depression, and anxiety increased the stress risk 1.50 times, 7.20 times, and 4.70 times, respectively. Table 4 showed that the results of the correlation analysis between depression, anxiety, stress, and sleep quality. The correlation between sleep quality and depression, anxiety, stress was found statistically significant, negative, and low level (p<0.05). It was found that the medical students having high depression, anxiety, and stress levels had sleeping problems (unable to start sleep or unable to continue sleep) and low sleep quality (Table 4).

Discussion
Depression, anxiety, and stress are the most common psychiatric disorders in the society. Depression among medical students is a worldwide phenomenon. Despite major changes in medical education, depression remains a major problem. In this context, depression (60.20%), anxiety (66.20%), and stress (62.60%) prevalence were common among the students of the Medicine Faculty of Afyonkarahisar Health Sciences University (Table 1). These results showed that the prevalence of depression, anxiety, and stress is higher than the previous studies in Turkey. 5,[17][18][19][20][21][22][23]28 Results of depression prevalence obtained from the present study were similar with the results obtained in some other countries: Cameroon 65.20% 29 32 . Because students are exposed to too much stress in addition to the normal stress factors of daily life, the prevalence of stress is high nearly in all countries. Comprehensive medical curriculum, long course hours, concerns about academic performance, high family expectations, and socio-demographic characteristics are some of these stress factors. Depression, anxiety, and stress levels were higher in second-grade students than in other grades (Table 2; Figure 1). In the literature, some other research studies emphasized the same result. 2,4,5,8,14,16 In contrast, Ediz et al. 24 found first grade students had a high depression, anxiety, and stress level. Also, Bayram and Bilgel 13 and Fuad et al. 19 indicated that pre-clinical students (first grade and second grade) had a high depression, anxiety, and stress level. It can be explained by the usual stress of the first and second-grade students who are newly acquainted with the academic environment. Moreover, Bassols et al. 34 indicated that sixth grade students had a lower depression, anxiety, and stress level than other grades. It can be explained by the fact that the sixth-grade students adapt to academic standing and do not have to take an exam. According to the results of binary logistic regression (Table 3), the poor economic level of the family, the use of energy substances, the short study duration during an exam period, anxiety, and stress increased the risk of depression. Being a woman, poor economic level of the family, low educational level of the father, the involuntary choice of medical faculties, poor sleep quality, stress and depression increased the anxiety risk. Being a woman, an unemployed father, poor sleep quality, anxiety, and depression increased the risk of stress. Similar risk factors for depression, anxiety, and stress were obtained from the related literature. 4,7,13,17,23 It was found that statistically significant, negative, and low-level correlation between sleep quality and depression, anxiety, stress. Sleep quality was found to be low in students with high levels of depression, anxiety, and stress (Table 4). Najafi Kalyani et al. 6 and Almojali et al. 11 also indicated that students with high levels of depression, anxiety, and stress had a low sleep quality. The results of this study were closer to the results of the studies conducted in the Middle Eastern, Asian, and Arabian countries. The prevalence of depression, anxiety, and stress among medical students in these countries has been generally higher than the ones in the European countries. High depression, anxiety, and stress levels may be due to cultural and religious differences between the Eastern and Western countries. Consequently, depression, anxiety, and stress levels were found to be high at the students of Medical Faculty of Afyonkarahisar Health Sciences University. Students with these problems need to be identified and it is necessary to take measures to solve these psychological problems. Providing individual guidance and psychological counseling services for medical students could be beneficial. Studies in the literature have shown that an important proportion of medical students have high levels of depression, anxiety, and stress. Making multicenter studies with the same methodology should be used to assess whether the differences in depression, anxiety, and stress rates are artificial or indeed exist. Finally, the evaluation of psychological morbidity is needed not only for students but also for other partners such as educators and parents.

Financial Support
This study was supported by the Afyon Kocatepe University Scientific Research Coordination Office with the number of "17.KARIYER.241".