Subjective experience of depressed mood among medical students at the University of Pretoria

Volume 14 No. 1 March 2008 SAJP In 2005, a 4th-year medical student at the University of Pretoria committed suicide a day before her mid-year exam. Her classmates felt stunned and guilty for not recognising her distress. In their words: ‘The news came to all of us as a shock, as she always appeared to be in control and sure of herself. ... somehow we all failed in recognising the burden that our classmate was carrying.’ Suicide in Pretoria by young people between the ages of 21 and 24 years accounted for 8.4% of all suicide victims. This is similar to the figures quoted in the guidelines by the American Academy of Child and Adolescent Psychiatrists (AACAP) for suicide management in adolescents, which state that suicide in the age group 20 24 years accounted for 8% of all suicide victims during 1997 in the USA, and that 7% of all deaths in this age group were attributable to suicide.

In 2005, a 4th-year medical student at the University of Pretoria committed suicide a day before her mid-year exam.
Her classmates felt stunned and guilty for not recognising her distress.In their words: 'The news came to all of us as a shock, as she always appeared to be in control and sure of herself.… somehow we all failed in recognising the burden that our classmate was carrying.'Suicide in Pretoria by young people between the ages of 21 and 24 years accounted for 8.4% of all suicide victims. 1 This is similar to the figures quoted in the guidelines by the American Academy of Child and Adolescent Psychiatrists (AACAP) for suicide management in adolescents, 1 which state that suicide in the age group 20 -24 years accounted for 8% of all suicide victims during 1997 in the USA, and that 7% of all deaths in this age group were attributable to suicide.
Tyssen et al. 3 and Wallin and Runeson 4 report that physicians run an increased risk of committing suicide, but that only a few studies have been done on suicide and suicidal ideation among medical students and young physicians.Tyssen identifies a number of risk markers associated with suicidal thoughts, including perceived study strain, personality factors and social support.Wallin and Runeson 4 report that 14% of final-year medical students had experienced suicidal ideation in their last year, but that few had attempted suicide.Poch et al. 5 add feelings of hopelessness as a risk factor for suicide.
They stated that 13.9% of Spanish students in their study reported moderate or severe hopelessness on the Beck's Hopelessness Scale, and concluded that there was a need to develop programmes or services that improve students' adaptation to university life.Tyssen et al. 3 give the following guidelines for preventive efforts to be successful: Programmes should: (i) reduce the experience of time pressure and interruptions at work; (ii) strengthen competence in coping with stress; and (iii) ensure proper mental health services.
Mueller and Waas 6 describe much higher levels of suicidal ideation among college students than among the general population, with 43% of their sample reporting suicidal ideation in the preceding year.They suggest that fellow students may be in the best position to recognise and assist their peers at risk.This study was prompted by the death of the 4th-year student as well as the paucity of literature to help guide one in the prediction and prevention of suicide.The aim was to examine feelings of hopelessness and suicidal ideation among medical students at the University of Pretoria, and their knowledge about and attitude towards help structures provided by the University.

Subjective experience of depressed mood among medical students at the University of Pretoria
L van Niekerk, Final-year medical student Other questions were about hope for the future; whether the student would change to another course if given the chance; and knowledge about and willingness to use support structures provided by the university.They were also asked to identify the support structures, if aware of such.
The questionnaire was distributed to all 1st-, 4th-, 5th-and 6th-year medical students at the University of Pretoria, as well as to a control group studying any course at the university other than medicine.The medical students received the questionnaire on an exam day, to promote participation.The control group was recruited at a general study hall of the same university.All participants had to be enrolled students at the University of Pretoria, and participation was voluntary and anonymous.All returned questionnaires were used for data analysis.The study was mainly a descriptive type.Statistical analysis was done using the F-test to detect variance in the two groups.

Results
A total of 416 medical students completed the questionnaire.
The control group comprised 250.There were no significant differences in the groups regarding gender or relationship status (that is, being single or in a relationship) (p=0.28),although the percentage of married medical students was double that of the other students (7% v. 3.2%) (see Table I).
Medical students tended to perceive the difficulty of their course as increasing with time, whereas the control group of students saw their 1st and 2nd years as the most difficult.
Sixty of the 75 final-year medical students regarded the 5th and/or 6th years as being the most difficult.Medical students also described themselves as feeling tired more often towards their later years of study (see Fig. 1).   in the past, and commented on the use of medication to alter their mood, regardless of whether this was obtained through a prescription or not.Table II shows the results in terms of previous diagnoses and medication use.No statistically significant differences were found between the groups of students.The 14.9% of students who reported having been diagnosed with a major depressive disorder is significant, considering the lifetime prevalence of major depressive disorder being between 5% and 25%. 7e medical student group rated their satisfaction with life slightly higher than the students studying other courses.This difference is not statistically significant, however (p=0.4)(see Fig. 2).Medical students also seemed more positive about the future than their counterparts (see Fig. 3).Satisfaction with life and hope for the future are factors that protect against suicidal thoughts or attempts, according to Paykel et al. 5 There were no statistically significant differences between the two groups of students in terms of suicidal thoughts or attempts.

Perceived tiredness
Although not statistically significant, students studying other courses reported higher rates of suicide ideation and previous attempts than the medical students, which does not support the hypothesis that medical students are at a higher risk for committing suicide than other students.These results appear in  III.
It is of concern that only 15.9% of medical students indicated that they were aware of support structures provided by the university for students experiencing difficulties.They were aware of support systems at the Hatfield (main) campus and the dean's office, as well as through the impaired students' committee and the mentoring programme.However, students were hesitant to make use of these services -only 29.3% indicated that they would be willing to seek support from them.Of the control group, 17.2% knew about the support structures to assist students, and 24% of them indicated that they would be willing to make use of these structures.

Discussion
This study is the first of its kind at a southern African university.
It was initiated as a result of concerns about the mental wellbeing of medical students.It was hypothesised that medical students were more at risk for suicidal ideation and   The results of this study suggested that, although the rate of depression and suicidal ideation is seemingly higher among medical students than the general population, they did not differ from students studying for other degrees at the university.The frequencies of 3.3% for often thinking of suicide, and 1.6% for previous suicide attempts reported by our medical students are, however, higher than those found by Tyssen et al. 3 Students studying for other degrees reported even higher rates of suicidal ideation and previous attempts than the medical students.Although Mueller and Waas 6 reported a much higher rate of suicidal ideation, they did not differentiate between degrees of suicidal ideation, and only asked for a yes/no response, which makes a comparison with our study difficult.Medical students were more likely to use mood-enhancing medication, which may be a reflection of their particular field of study.
It is notable that medical students perceive their studies as  Another limitation was that two-thirds of the junior medical students (i.e. the 2nd and 3rd years) were not included in the study.Their inclusion might have biased the results for which year medical students perceived as the most difficult.
However, since the more senior medical students often indicated more than one year as being the most stressful, this factor may be negligible.
The study was further limited in that it did not examine the influence of students working after hours to sustain themselves.
It was known to us that a number of medical students worked after hours, often doing night shifts, to pay for their studies.
This may be a factor contributing towards medical students reporting feelings of tiredness more than other students -if medical students differ from other students in this respect.By looking after the mental wellbeing of our medical students, we may prevent unnecessary suffering associated with suicide ideation, and even suicide.The university setting provides the ideal opportunity to sensitise people to their own mental health needs and enables them to get the necessary help and support.Studies such as these may guide the provision of appropriate services for vulnerable students.

Conclusion
The initiative for this study came from a group of (then) 4th-year students who were looking for a way to prevent similar tragedies to that of their classmate.The students conceptualised and planned the study as well as doing the data collection.They subsequently initiated, negotiated and set up a website for medical students in an effort to facilitate help-seeking.Their empathy and initiative should be acknowledged.

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Students reported the diagnosis of major depressive disorders and other psychiatric diagnoses that might have been made

Currently, the
University of Pretoria offers a psychological support team and a student-based mentorship programme, as well as academic and financial support services.All medical students are informed of these support services and how to access them in their first year of study.The mentorship programme is run under the guidance of full-time medical personnel at the teaching hospitals.The small percentage of students aware of these support structures, and the hesitance to use them, are of concern.Support structures can only be utilised effectively if students are aware of them and are willing to use them.Tyssen et al. 3 concluded in their study that preventive efforts should be directed at: (i) reducing the effects of time constraints; (ii) improving stress-coping strategies; and (iii) ensuring proper mental health services.Although the University of Pretoria has support systems in place that address all of these points, this study indicates a widespread unwillingness to make use of the systems.If this cannot be rectified, support services rendered by the university cannot be fully effective.This study did not address the reasons for the hesitance among students to make use of support services, which calls for a follow-up study.Nevertheless, in an attempt to increase both awareness and utilisation of support services, medical students have recently launched a website for students where information and contact details are easily accessible and anonymously available.