Introduction

Studies have suggested that resident physicians experienced high rates of stress and depression [1]. This is so because of increased expectations and responsibilities and the fact that residents are expected to be proficient clinicians, educators, researchers and administrators at the end of their training. Beyond the effects of depression on individual’s health, resident depression has been linked to poor-quality patient care and increased medical errors [2]. Estimates of the prevalence of depression was reported to be up to 60% [3]. Stress had been linked with musculoskeletal disorders, high blood pressure, disturbed metabolism, cardiovascular problems, mental health problems and premature mortality [4]. Physicians are exposed to many stressors, such as the burden imposed by expectations of a high degree of professionalism, responsibility for patient well-being and maintenance of relationships with patients and health workers, as well as concerns about medical errors and malpractice litigation [5]. Such occupational stressors had been reported to be associated with depression and stress among residents [6]. This study aims to assess level of stress and depression and associated factors among family medicine residents in Al-Madinah, Saudi Arabia.

Material and Methods

This cross-sectional study is a part of bigger study [7]. All residents in the family medicine residency programs in Al-Madinah were asked to participate in this study (n=105). Participants were approached two months before exam to avoid the stressful examination period.

A self-administered questionnaire consisting of three parts was used in this study. The first part included questions on sociodemographic and work characteristics. The second part assessed stress and depression by using the stress and depression subscales of the validated Depression, Anxiety and Stress Scale-21 item (DASS-21). Stress subscale contains seven items and assesses difficulty relaxing, nervous arousal, and being easily upset/agitated, irritable/over-reactive and impatient [8]. Depression subscale contains seven items and measures hopelessness, low self-esteem and low positive affect. Each item is scored on a four-point Likert scale ranging from zero (Did not apply to me at all over the last week) to three (Applied to me very much, or most of the time over the past week). Total score of stress and depression were obtained by summing up the relevant questions of each subscale. Sources of stress were assessed by 22 items which were obtained from the literature. These items were headed by the following question: “to which extent dose the following conditions cause stress to you”. Each item was scored from zero (Causing no stress) to 4 (Causing severe stress).

Analysis was performed using Statistical Package for the Social Sciences (SPSS®) (version 22.0, IBM, Armonk, NY). Total score of stress and depression were multiplied by 2. Test of normality was performed for the total stress scale and depression scale. To check for the factorial structure validity of the Stress and Depression Scale, an exploratory factor analysis was performed using principal component method with varimax rotation. The analysis yielded two-factor structure. Cronbach’s alpha of stress scale and depression scale were 86% and 88%, respectively, which indicate satisfactory internal consistency. Total score of stress and depression were categorized to ‘normal’, ‘moderate’, ‘severe’ and ‘extremely severe’ according to the recommended cut-off scores [9]. To assess the association between the continuous and the categorical variables, we used t-test and ANOVA test. Correlation analysis was used to assess the association between the continuous variables. To obtain the significant factors associated with stress and depression, multiple linear regression analysis was employed by using “Backward” technique. Multi-collinearity was checked between the independent variables by using the VIF (Variation Inflation Factor). The accepted level of significance was set below 0.05 (p<0.05).

Ethical considerations

Ethical approval was obtained from the ethical committee of the Directorate of Health in Al-Madinah. Objectives and benefits of the study were explained to the participants. Participant’s confidentiality and anonymity were assured. Signed consent was obtained from the participants.

Results

Out of 105 residents, 75 completed the survey (71% response rate). Respondents and non-respondents were compared on available demographic variables and no significant differences were found.

Most respondents were female (45.3%), aged 28-30 years (84.0%) and singles (50.7%). Working in shift was reported by 28.0% of respondents. Most of the respondents were in their first year in study (33.3%) and had 1 to 2 years of experience since graduation (62.7%). Academic performance was reported as poor by 9.3%, good by 48.0%, very good by 36.0% and excellent by 6.7% of the respondents (Table 1).

The five most important stressors ranked by residents were tests/examinations, large amount of content to be learnt, fear of making mistakes, work overload, time pressures and deadlines to meet (Table 2).

The mean (SD) stress score was 16.6 (9.4) and stress score ranged from zero to 42. About 46.7% of the residents had no stress, 16.0% had mild stress and 17.3% had moderate stress. Severe and extremely severe stress were reported by 14.7 % and 5.3% respectively. The mean (SD) depression score was 12.9 (9.8) and depression score ranged from zero to 42. About 42.7% of residents had no depression, 20.0% had mild depression, and 14.7% had moderate depression. Severe and extremely severe depression was reported by 10.0% and 12.0% respectively (Table 3).

Participants who were working in shift had significantly higher stress compared to those who were not (P=0.013) (Table 4).

Stress was correlated positively and significantly with all sources of stress in this study. Correlation coefficient ranged from 0.23 (weak correlation) to 0.65 (moderate correlation) (Table 5). Depression was correlated positively and significantly with 8 out of 22 sources of stress. The highest correlation was with the item ‘work demands affect my personal/home life’ (r=0.50, P<0.001) (Table 5).

(Table 6) exhibits the predictors of stress and depression among family medicine residents in multivariate analysis. The significant predictors of stress in the final model were work overload (P=0.032), work demands affect personal/home life (P<0.001), inability to participate in decision making (P=0.026) and inability to make full use of skills and abilities (P=0.019). The total model was significant (P<0.001) and explained 46% of the variance of stress score. There was no multi-collinearity between independent variables, given that the variation inflation factor (VIF) values were less than 10.

Regarding depression score, the only significant predictor was ‘Work demands affect personal/home life’ (P<0.001). The total model was significant (P<0.001) and explained 19% of the variance of depression score.

Discussion

In this study, 53.3% residents had stress. A previous study in Saudi Arabia (2015) found that the prevalence of stress among family medicine residents was 63.2%. The prevalence of stress in the previous international studies ranged from 17.7% to 42% [10-13]. The higher prevalence found in the current study could be related to the differences in working environment, cultural difference, sources of stress, and the health system. Also, the difference between different residence programs could affect the level of stress among residents. Our study showed that stress was correlated positively and significantly with all sources of stress (22 sources). In the previous studies, sources of stress were associated significantly with stress and burnout among residents and medical students. The most-reported stressors include work environment, work overload, academic stressors, tests and examinations, lack of family support, financial difficulties, relationships with trainers and colleagues, unclear long-term career future, long working hours, time pressures, excessive assignments and fear of making mistakes [14-19].

In this study, stress was associated significantly with working in shift but not with socio-demographic characteristics. Similarly, working in shift was associated with stress in the previous studies [20, 21]. Depression among residents has been linked to a higher risk of future depressive episodes and greater long-term morbidity and may affect the long-term health of resident doctors. In this study, 57.3% of the participants exhibited depressive symptoms. The prevalence of depression among residents in the previous studies ranged from 19% to 43.2% [22]. A higher prevalence of depression was found in a previous study in Dubai (63.3%). Depression was correlated positively and significantly with 8 out of 22 sources of stress in this study. Anagnostopoulos F also demonstrated associations between residents' mental health and sources of stress [23].

This study is not without limitations. First, the study sample included residents from one center of family medicine resident program in Saudi Arabia. Second, using a cross-sectional study design precluded the detection of any causal association. Moreover, we cannot exclude the possibility of reporting bias from self-reported data. Finally, the sample size is relatively small although we had a good response rate. The small sample size may have reduced the power of the study to detect differences between groups.

Conclusions

The prevalence of stress and depression among family resident doctors in this study was 57.3% and 53.3% respectively. Sources of stress were significantly associated with stress and depression. Establishing a residency counseling office is suggested to deal with the resident's problems in a way that supports their needs and leads to the best working environment.

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