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Perceived depression, anxiety and stress among Saudi postgraduate orthodontic students: a multi-institutional survey.

Byline: EMAN I. AL-SHAYEA

The aim of the study was to investigate three negative emotional states: depression anxiety and stress in Saudi postgraduate orthodontic students. A modified Depression Anxiety Stress Scale (DASS) questionnaire was sent electronically to eighty-four postgraduate orthodontic students in various years of two different programs (Master and Saudi Board in Orthodontics programs) in three dental schools of different regions in Saudi Arabia. Frequency distributions of the dependent variables were derived and comparisons were made by non-parametric tests. Regression analysis was carried out to evaluate the influence of the demographic (independent) variables on each emotional state. The scores for depression anxiety and stress symptoms were 13.3 (5.7) 10.3 (4.8) and 21.3 (6.4) respectively. No differences were found in terms of gender and years of study of the respondents for the depression anxiety and stress scales. Married students and those older than 30 years were found to exhibit a lower level of anxiety symptoms than those who were single and thirty years old or younger. These results indicated a need for student-oriented programs to provide appropriate support to the students with a special attention to single and young students.

Key Words: Depression anxiety stress orthodontic students DASS.

INTRODUCTION

Occupational stress can be defined as a state of physical and mental tension resulting from excessive demands or lack of resources.1 Depression is defined according to the World Health Organization (WHO)2 as a common mental disorder characterized by sadness loss of interest or pleasure feelings of guilt or low self- worth disturbed sleep or appetite feelings of tiredness and poor concentration. Anxiety is characterized by feelings of tension worried thoughts and physical changes like increased blood pressure as defined by the American Psychological Association.3 Studies conducted in several countries have demonstrated the omnipresence of stress depression and anxiety among dental students4-15 which has resulted in an increased interest in stress management programs for dentists.16

Many studies5141718 have demonstrated that the dental students had the highest mean stress scores and the second lowest social support scores compared to other professional students.

Stress in the dental training environment is mul- tifactorial and several potential stressors have been identified including time and scheduling pressures the need to meet academic and clinical requirements examination anxiety grade competition patient man- agement (coming late or not showing up for appoint- ments) litigation from patients financial concerns practice of clinical dentistry career choices age and gender.57121519 Social support has also been identified as a major stressor; social support refers to interper- sonal relationships whether emotional informational or instrumental support (i.e. financial aid).13 Some researchers have investigated living arrangements and marital status as proxy measures of social support suggesting that students who resided at home during term-time appeared to have some protection against stress.51315 Mathias et al (2005) found that married dental professionals exhibited less depression and stress than those who were unmarried divorced or widowed.

Madhan et al (2012) found a suboptimal level of mental health among postgraduate orthodontic

students in India and highlighted the need for a more favorable academic environment. A study of seven European dental schools has shown that the level of emotional exhaustion was higher in dental students than in medical students.5 The study also found that general psychological distress and course-related stress levels were associated with the nature of the course and the immediate living conditions of the students. Another study conducted in three European dental schools identified several sources of stress in dental students which included limited leisure time exam- ination anxiety and adaptation to the clinical phase of dental education.7

In addition a cross-sectional multinational survey of nine dental schools in seven countries found the student's emotional intelligence to be the most significant independent predictors of perceived stress.12 These researchers and others found that those students who were satisfied with their decision to study dentistry were less likely to report perceived stress.4610-12 Muirhead and Locker (2008)13 identified social support and proxy measures as significant predictors of dental school stress in Canadian dental students. Furthermore another multi-country study in six European dental schools found that the main concern for dental students were self-efficacy beliefs assigned workload and performance pressure.21

Gender differences in depression symptoms have also been reported with female students experienc- ing a higher level of psychological disturbances than males.81215192223 This finding however contradicts a number of previous studies that did not demonstrate any gender-derived differences in any psychological variable.51424 While dental students' stress and psycho- logical disturbances are well-recognized and reported in undergraduate students such information is scarce among postgraduate dental students. Therefore the purpose of the present study was to determine the degree of psychological disturbances and to assess the extent of three emotional states (stress depression and anxiety) among postgraduate orthodontic residents in Saudi Arabia through a short version of the Depression Anxiety Stress Scale (DASS-21) questionnaire.25

METHODOLOGY

A cross-sectional survey was conducted in three dental schools in different regions of Saudi Arabia; Riyadh (Central Region) Jeddah (Western Region) and Dammam (Eastern Region). The study population was Saudi postgraduate orthodontic students enrolled in two different postgraduate programs; a three-year program of Master of Science in Dentistry and Certif- icate of Specialty in Orthodontics and the second a

five-year program called Saudi Specialty Certificate Program in Orthodontics (Saudi Board) conducted by Saudi Commission for Health Specialties. Both pro- grams are approved and accredited by the Ministry of Higher Education and the Saudi Commission for Health Specialties.

Lovibond and Lovibond (1995)25 shorter version of the Depression Anxiety Stress Scale (DASS-21) was utilized for the present study. The DASS-21 is a modified version of the original forty-two items survey (DASS-

42). It is a set of three self-reported scales designed to measure the negative emotional states of depression anxiety and stress in an individual.2526 The DASS-21 has twenty one items seven items for each emotional state divided into subscales with similar contents. The Depression scale assesses dysphoria hopelessness devaluation of life self-deprecation lack of interest/ involvement anhedonia and inertia. The Anxiety scale assesses autonomic arousal skeletal muscle effects situational anxiety and subjective experience of anxious effect. The Stress scale assesses difficulty in relaxing nervous arousal susceptibility to agitation irritable/ over-reactive state and impatient.

Scores for Depression Anxiety and Stress are calculated by summing the scores for the relevant items and then multiplied by two. The scale severity is interpreted as shown in Table 1. (The survey is available at www.psy.unsw.edu.au/dass). The DASS-21 questionnaire was sent electronically to 84 postgrad- uate orthodontic students in various years of the two postgraduate programs along with an explanation of the purpose of the study and the research procedure. The students were asked to voluntarily complete the anonymous questionnaire.

The questionnaire had two sections. The first sec- tion recorded demographic details that included age gender name of the program year of study (Master: I II and III) (Board I II III IV and V) marital status and medical condition with history of any systemic disease prolonged systemic medication or serious life event the students may have experienced in the past six months. Those who responded positively to having experienced any of these situations were excluded from the study. The second section comprised of the DASS-

21. The students were asked to rate various items on a scale of 0 (did not apply to me at all) to 3 (applied to me very much or most of the time).

Ethical approval of the study was obtained from Ethical Committee of College of Dentistry Research Center (CDRC) at King Saud University. The survey was sent in the middle of an academic semester and closed at the end of the same semester (November-December 2013). The data were tabulated and cross-checked. Data processing and analysis were carried out using the statistical package for social sciences (SPSS) software version # 20.

Frequency distributions for gender age group marital status program of study and year of study were generated. Group comparisons (for gender age program of study and marital status) were performed with the Mann-Whitney test and comparisons based on year of study were carried out with Krus- kal-Wallis test for each emotional state (depression anxiety and stress). Finally in order to evaluate the influence of the demographic variables independently on each effective state a logistic regression analysis was carried out with the presence or absence of a moderate or higher level of the symptom entered as the dependent variable. Statistical significance was set at p less than 0.05.

RESULTS

Seventy-nine questionnaires were returned com- pleted electronically giving a 94% response rate. The mean age of the respondents was 32 (4) years with a median of 31 years; and range from 25 to 45 years. The demographic details of the participants are presented in Fig 1. Tables 2 3 and 4 respectively summarize the mean median and standard deviation for the depres- sion anxiety and stress scales according to gender marital status age study program and year (level) of the study.

For the overall sample the mean score of depression was 13.3 (5.7) Table 2. The mean scores for anxiety and stress symptoms were 10.3 (4.8) and 21.3 (6.4) respectively (Table 3 and 4). There was no significant statistical difference in terms of gender for the de- pression anxiety and stress scores. Married students and those older than 30 years were found to exhibit a lower level of anxiety than those who were single

TABLE 1: DASS SEVERITY RATINGS AFTER MULTIPLYING SUMMED SCORES IN EACH CATEGORY BY TWO

Severity###Depression Anxiety Stress

Normal###0-9###0-7###0-14

Mild###10-13###8-9###15-18

Moderate###14-20###10-14###19-25

Severe###21-27###15-19###26-33

Extremely Severe###28+###20+###34+

and thirty years or younger (9.72 vs 11.19 and 9.77 vs 11.13; p = 0.020 and 0.007) Table 3. However no significant difference was found between these groups for the depression and stress scores (Tables 2 and 4). The students who were pursuing a Master of Science in Dentistry and Competency Certificate in Orthodontics had experienced a higher level of depression symptoms than those who were enrolled in a five-year Saudi Specialty Certificate Program in Orthodontics (14.26 vs 12.60 p = 0.013) Table 2. However there was no significant difference between the students enrolled in both programs for the anxiety and stress scores (Tables 3 and 4).

The study found no significant difference between the students in various years of the programs for all three emotional states. The distribution of the sample according to the severity categories is shown in Fig 2. About six in ten (40.5%) of the participants had de- pression at mild levels while more than half (51.9%) of the participants experienced stress at moderate levels. Very few participants exhibited depression anxiety and stress at extremely severe level (2.5% 6.3% and 2.5% respectively).

The binary logistic regression analysis (Table 5) showed that both males and females and students in each year of study similarly experienced the three emotional states from moderate to severe levels. Mar- ried students and those older than 30 years were less likely to show moderate or higher levels of anxiety symptoms (odds ratio = 0.37 0.19 respectively p less than

0.05) than those who were single and thirty years of age or younger. Students who were pursuing a Master of Science in Dentistry were two times more likely to experience depression at moderate or higher levels than those who were enrolled in five-years Saudi Board Program (odds ratio = 2.05 p less than 0.05).

DISCUSSION

Information is scarce in areas of depression anxiety and stress among postgraduate dental students. The present study has fielded important information about the above stated emotional states in postgraduate stu- dents in orthodontics. It is hoped that the present study has provided base-line data for future comparisons and development of support services for the postgraduate students.

Highest ranked stressors reported in dental stu- dents appear to be independent of the culture teaching methods dental program lengths or the student's

TABLE 2. DESCRIPTIVE STATISTICS AND GROUP COMPARISONS (MANN-WHITNEY AND KRUS-KAL-WALLIS TESTS) FOR DEPRESSION SCALE

Variable###Mean###95% CI###Median###SD###Sig. (P value)

Gender###Male###13.27###11.15-15.39###12###6.34###NS (0.44)

###Female###13.24###11.61-14.86###14###5.21

Marital status###Married###13.09###11.47-14.70###13###5.50###NS (0.35)

###Unmarried###13.50###11.29-15.71###14###6.13

Age###greater than 30 years###13.55###12.03-15.08###13###5.20###NS (0.16)

###30 years###12.81###10.47-15.16###12###6.49

Study program###Master###14.26###12.55-16.58###14###6.34###(0.013)

###Board###12.60###11.07-12.97###12###5.27

Year of study###1st year###13.91###10.82-16.99###13###4.59

###2nd year###12.10###8.72-15.47###12###5.04###NS (0.85)

###3rd year###14.11###12.19-16.02###13###4.93

###4th year###13.91###9.71-18.11###12###6.23

###5th year###11.50###8.04-14.96###12###4.14

Overall sample###13.25###13.25###11.97-14.54###13###5.73

TABLE 3. DESCRIPTIVE STATISTICS AND GROUP COMPARISONS (MANN-WHITNEY AND

###KRUSKAL-WALLIS TESTS) FOR ANXIETY SCALE

Variable###Mean###95% CI###Median###SD###Sig. (P value)

Gender###Male###9.92###8.05-11.79###9###5.61###NS (0.12)

###Female###10.67###9.40-11.93###10###4.05

Marital status###Married###9.72###8.98-10.56###9###4.78###(0.020)

###Unmarried###11.19###10.49-12.93###11###4.84

Age###greater than 30 years###9.77###8.39-10.14###9###4.68###(0.007)

###30 years###11.13###10.32-12.39###11###5.00

Study program###Master###10.48###8.63-12.34###10###5.05###NS (0.82)

###Board###10.21###8.84-11.58###9###4.72

Year of study###1st year###10.36###7.39-13.34###9###4.43

###2nd year###10.52###8.43-12.62###10###4.60###NS (0.71)

###3rd year###10.57###8.51-12.63###9###5.30

###4th year###10.82###6.89-14.74###9###5.84

###5th year###8.13###5.87-10.38###8.5###2.70

Overall sample###10.32###9.24-11.40###9###4.83

TABLE 4: DESCRIPTIVE STATISTICS AND GROUP COMPARISONS (MANN-WHITNEY AND

###KRUSKAL-WALLIS TESTS) FOR STRESS SCALE

Variable###Mean###95% CI###Median###SD###Sig. (P value)

Gender###Male###20.68###18.75-22.60###21###5.77###NS (0.14)

###Female###21.83###19.68-23.99###23###6.92

Marital status###Married###21.62###20.02-23.21###23###5.44###NS (0.77)

###Unmarried###20.81###18.05-23.57###22###7.66

Age###greater than 30 years###21.94###20.26-23.61###23###5.72###NS (0.29)

###30 years###20.34###17.72-22.97###21###7.27

Study program###Master###20.58###18.38-22.78###22###5.99###NS (0.20)

###Board###21.75###19.82-23.68###23###6.66

Year of study###1st year###22.00###17.56-26.44###24###6.60

###2nd year###18.38###14.63-22.13###20###8.24###NS (0.56)

###3rd year###21.46###19.71-23.22###22###4.53

###4th year###24.73###21.34-28.11###24###5.04

###5th year###22.63###17.51-27.74###23###6.12

Overall sample###21.29###19.86-22.72###22###6.40

TABLE 5: BINARY LOGISTIC REGRESSION ANALYSIS FOR MODERATE OR HIGHER

###SEVERITY OF SYMPTOMS

Scale (dependent)###Variable (independent)###B###SE###Odds Ratio###Sig.###R2

Depression###Female###1.02###0.55###1.42###NS

###Married###-0.99###0.59###0.76###NS

###Age greater than 30 years###1.13###0.73###0.56###NS

###Master###0.72###0.59###2.05###0.164

###Program###1.73###0.27###0.32###NS

###1st year###1.47###0.78###1.23###NS

###2nd year###1.63###0.97###0.73###NS

###3rd year###0.97###0.56###0.86###NS

###4th year

Anxiety###Female###1.04###0.54###0.57###NS

###Married###-0.78###0.58###0.37###

###Age greater than 30 years###0.96###0.74###0.19###NS

###Master###0.40###0.59###0.86###NS

###Program###1.79###0.27###1.22###NS###0.175

###1st year###2.16###0.87###0.52###NS

###2nd year###1.58###0.66###0.98###NS

###3rd year###0.91###0.45###0.55###NS

###4th year

Stress###Female###0.82###0.65###0.35###NS

###Married###0.18###0.68###0.87###NS

###Age greater than 30 years###0.22###0.77###1.20###NS

###Master###-0.12###0.64###0.47###NS###0.243

###Program###0.13###0.33###1.60###NS

###1st year###-1.62###0.46###0.44###NS

###2nd year###-0.40###0.72###0.78###NS

###3rd year###0.35###0.27###0.35###NS

###4th year

specific year of study.4152728 Although each student will experience the stress of professional training somewhat differently the cumulative effect of these stressors can lead to depression anxiety substance misuse dimin- ished work efficiency and exhaustion.4152728 In a Euro- pean study of stress in dental students the researchers found that 10% of the dental students suffered from severe emotional exhaustion; 17% complained about a severe lack of accomplishment and 28% experienced severe depersonalization symptoms.7 The present study was conducted within this context to assess the extent of three emotional states; depression anxiety and stress among postgraduate orthodontic residents in Saudi Arabia. The study used the short-form version of the Depression Anxiety Stress Scale-21 items (DASS-21) due to its reliability measurement validity its relatively intelligible language simple procedures and suitability for both clinical and research purposes.2930 The overall results of the study showed that the level of depression among the participants was slightly higher while the levels of anxiety and stress were moderately higher than the contemporary norms.3132 Similar findings have been previously reported for depression and stress

symptoms by Madhan et al19 in Indian postgraduate orthodontic students. However they did not find any student reporting depression or anxiety to extremely severe level.

Many studies have examined depression anxiety and stress in undergraduate dental students and den- tal practitioners; and have shown that the concerns of dental students mirror those of qualified dental prac- titioners.5620 Ahola and Hakanen33 found a reciprocal relationship between burnout and depressive symptoms in dentists. The findings of a high level of occupational stress in the present study are consistent with previous studies amongst undergraduate dental students and general dental practitioners.51534-36

In the present study females and males showed similar levels of depression anxiety and stress. This is consistent with previous studies which have argued that gender-derived differences in dentists may have become a thing of the past.51424 In contrast some re- searchers have reported that female dental students are more likely to express their perceptions of stress 12192336 arguing that it is easier for female students to express their experiences of stress than male students.12 The results of the present study also showed that students older than 30 years of age exhibited a lower level of anxiety symptoms than those who were thirty years or younger though the association between age and anxiety was not significant in regression analysis. In addition the findings of the present study also indi- cated that married students were less likely to report anxiety symptoms compared to their unmarried coun- terparts. This finding was supported by the result of regression analysis for moderate or higher severity of symptoms. The explanation for reported lower anxiety among married students may be that marriage is con- sidered as a measure of social support. Several studies suggest that home environment and marriage offered some protection against dental school stress.51537 A cross-sectional study by Musser and Lloyd found that married students had the lowest reported total mean stress score than unmarried students.38

Results showed a higher level of depression symp- toms among students who were pursuing three-year Master's Degree compared to those who were pursuing five-year Saudi Board. The higher level of stress among the Master students could be attributed to the fact that it is a condensed three years program and hence more demanding. The mean scores of depression anxiety and stress were similar in all years of both the programs. This in contrast with previous studies which showed

an increase in the overall student stress levels as the student progresses in his/her program.61539 Most of these studies attributed their finding to the student's transition from preclinical into clinical training which is not applicable to the present study; since the all par- ticipants were postgraduates and started their clinical training from the first year of their programs.

The results of the present study have to be in- terpreted keeping in sight the small sample size and cross-sectional nature of the study. In addition some factors (such as curricula teaching and learning methods and training environment) that may influ- ence the level of depression anxiety and stress were not included in the study. Nevertheless high levels of depression anxiety and stress manifested in this study suggest that student-oriented programs should be implemented to provide appropriate support systems and management for the students enrolled. Further research is needed with larger sample size to establish native population norms for Depression Anxiety Stress Scale. Research is also needed to identify the sources and consequences of dental students' stress and to test its impact longitudinally on perceptions of stress in postgraduate dental students.

CONCLUSION

- The postgraduate orthodontic students were found to experience mildly elevated levels of depression and moderately elevated levels of anxiety and stress symptoms.

- Females and males experienced similar levels of depression anxiety and stress symptoms.

- Married students reported lower levels of anxiety symptoms compared to their unmarried counter- parts.

- Master's degree program students showed a higher level of depression symptoms compared to Saudi Board students.

- No significant difference was found in depression anxiety and stress levels between the students from various years in both the postgraduate programs.

Acknowledgment

The author is grateful to Mr. Nasr Al-Maflehi for his help and advice in statistical analyses. The author would also like to thank all the postgraduate orthodontic students for participating in this study.

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Author:Al-Shayea, Eman I.
Publication:Pakistan Oral and Dental Journal
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Date:Jun 30, 2014
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