Factors and Prevalence of Depression in Students at Iran’s Urmia University of Medical Sciences

Background: Depression is characterized by decreased tendency to work, reduced pleasure from work, increased or decreased weight, increased or decreased appetite, insomnia or narcolepsy, irritability, fatigue, loss of energy, feelings of worthlessness, feelings of guilt, reduced ability to concentrate and think, and thoughts of suicide or actual suicide attempts. In this 2016 study, we examined the factors and prevalence of depression in students at Urmia University of Medical Sciences in Urmia, Iran. Methods: This cross-sectional study was conducted on 400 students. Data were collected through the Beck Depression Inventory II (BDI-II): a 21-item standard questionnaire in multiple-choice format to evaluate depression. The questionnaires were distributed randomly by trained students over a period of 5 months. Data were analyzed using SPSS ver. 19 software and by descriptive statistics, independent t-tests, logistic regression models, and the chi-squared test. Results: The mean BDI score was 14.67 ± 11.30. Of the study population, 278 (69.8%) were men and 120 (30.2%) were women. In terms of depression, 40.2% of the students were in the normal range and had no depression, 23.6% were slightly depressed, and 18.3% were partially depressed. Also, 6.03% of students had severe depression, and 3.51% of students had very severe depression. No statistically significant relationship was observed between depression and sex (P = 0.11). However, significant relationships were observed between depression and education level (P = 0.001), smoking history (P = 0.001), and age (P = 0.023). P values less than 0.05 were considered statistically significant. Conclusion: The prevalence of different degrees of depression in the plurality of students at Urmia University of Medical Sciences necessitates the development and institution of psychological training classes.


INTRODUCTION
Depression is characterized by decreased tendency to work, reduced pleasure from work, increased or decreased weight, increased or decreased appetite, insomnia or narcolepsy, irritability, fatigue, loss of energy, feelings of worthlessness, feelings of guilt, reduced ability to concentrate, and thoughts of suicide or actual suicide attempts (1).Worldwide, depression is a leading cause of pathogenicity and disability and is a widespread and harmful disease that can affect any person regardless of age (2).It is a chronic disease that can disrupt work, family, and society (3).Depression can negatively affect people's physical health, mental health, emotions, and behavior.It can also increase the risk of cardiovascular disease and diabetes (4).In 1990, depression was considered the fourth most costly disorder worldwide; by 2015, it was probably the second most costly disorder worldwide (5).Many factors are associated with depression, among which depression, 17% had moderate depression, 5% had severe depression, and 2% had very severe depression (8).Students become depressed for various reasons, such as anxiety about passing the university entrance examination, concerns about future job prospects, separation from family, interaction with students from different cultures, living in dormitories, and having to make new friends (9,10).Some studies show that in the puberty period, the relevant changes can develop depression such as harmonic changes (11)(12)(13).
Depression in students is an important issue because it impairs their academic achievement and prevents them from reaching their full potential.To help reduce the rate of academic failure and to increase their performance in education field, it is necessary to identify the causes and factors of depression in students.The high rate of depressed students in Iran indicates the importance of conducting studies that address this serious socio-medical problem.Therefore, in this 2016 study, we examined the factors and prevalence of depression in students at Urmia University of Medical Sciences.

METHODS
In this cross-sectional study, conducted in 2016 at Urmia University of Medical Sciences, the Cochrane method in a known population was used.The sample size was 400 paticipants.Particpants were randomly selected.The error level was 0.05, P = 0.6, and the accuracy was 0.05; these values were obtained according to the following formula: N= Npqz2/pqz2+Nd2≈400.
Data were collected through the Beck Depression Inventory II (BDI-II): a 21-item questionnaire in multiple-choice format to evaluate depression.This standard questionnaire is scored by a simple Likert method from 0 to 3. The minimum score is 0; the maximum score is 63.The range of 0-10 is considered normal, 11-16 indicates minor depression, 17-20 indicates the need for psychiatric consultation, 21-30 indicates average depression, 31-40 indicates severe depression, and more than 40 indicates very severe depression (14).
The BDI evaluates feelings of disappointment, defeat, hopelessness, guilt, worthlessness, dissatisfaction, sinfulness, being punished, being disgusted, being reproached, inclination to suicidal weeping, being touchy, apathy to other people, inability to make decisions, bad feelings about one's appearance, insomnia, fatigue, loss of appetite, loss of weight, anxiety about health, decrease in sexual activities, loss of interest or pleasure in hobbies, and decreased energy (15).The validity and reliability of the Farsi version of BDI-II has been approved for use in Iran (16).
Each participant was informed about the purpose and objectives of the study and, after providing consent, was given a questionnaire.The questionnaires were distributed randomly by trained students in the Faculty of Nursing and Midwifery, the Faculty of Health, the Faculty of Paramedicine, the Faculty of Pharmacy, and the Faculty of Dentistry over a period of 5 months.We asked participating students to answer questions with great patience.This study was approved by the Ethics Committee of Urmia University of Medical Sciences and extracted from approved design (ID code: 1395-2283).
Participants were informed that their information would be kept secret and that they could leave the study at any time.Data were analyzed using SPSS ver.19 software.Descriptive statistics of the variables were classified according to their type in frequency, percentage, mean, and standard deviation.To test the hypothesis of the research, independent t-tests, logistic regression models, and the chi-squared test were performed.P values less than 0.05 were considered statistically significant.

RESULTS
In this study, 398 students participated (two students did not answer the questionnaire).The mean age was 22.35 ± 3.81 years.The mean BDI score was 14.67 ± 11.30.In terms of depression, 40.2% of the students were in the normal range and had no depression, 23.6% were slightly depressed, 18.3% were partially depressed, 6.03% were severely depressed, and 3.51% were very severely depressed.
As shown in Table 3, 30% of women were normal, 40% were slightly depressed, 20% were severely depressed, and 10% were very severely depressed.Of the men, 41% were normal, 21.6% were slightly depressed, 20.5% were partially depressed, 4.5% were severely depressed, and 3.5% were very severely depressed.No statistically significant relationship was observed between depression and sex (P = 0.11).
Of students who lived in dormitories, 23% were partially depressed, 5.8% were severely depressed, and 4.7% were very severely depressed.Also, 39.1%, 55.5%, and 23.5% of undergraduate, postgraduate, and doctoral students were normal.A significant relationship was observed between depression and education level (P = 0.001), so that 18.75% of undergraduate students were partially depressed.12.7% were severely depressed, and 7.44% were very severely depressed.
Of single students, 20.1% were partially depressed, 4.42% were severely depressed, and 3.86% were very severely depressed.Of married students, 22.2% were severely depressed.However, no significant relationship was observed between marital status and depression (P = 0.335).In terms of age, 18% of students aged 18-23 years were partially depressed, 6.8% were severely depressed, and 3.75% were very severely depressed.A statistically significant difference was observed between participant age and degree of depression (P = 0.023).

DISCUSSION
In our study of the factors and prevalence of depression in students at Urmia University of Medical Sciences, we found that approximately 40% of the students were in the normal range and had no depression, 23.6% were slightly depressed, 18.3% were partially depressed, 6.03% were severely depressed, and 3.51% were very severely depressed.No statistically significant relationship was observed between depression and sex (P = 0.11).However, a significant relationship was observed between depression and education level (P = 0.001), smoking history (P = 0.001), and age (P = 0.023).
In 2012, Hadavi and Rostami conducted a study of Rafsanjan students in the Nursing and Paramedical Faculties at Shahid Beheshti University of Medical Sciences (9).In this study, 400 students were enrolled.They found that 142 men (35.5%) and 203 women (50.7%) suffered from different degrees of depression.The frequency of depression in terms of grade were 44% in the laboratory sciences, 39.3% in the operating room, 39.1% in radiology, 35.2% in anesthesia, 31.6% in medical emergencies, 25% in nursing, and 24% in midwifery.A significant relationship was observed between depression and sex (P <0.008), mother's occupation (P <0.002), father's occupation (P <0.001), and maternal education (P <0.001) (9).Their results were inconsistent with ours in terms of the relationship between sex and depression.
However, regarding the high prevalence of depression in students, the results were consistent.
Another study conducted by Rostamzadeh and Khalilzadeh in 2007 on 3,023 high school girl students in Urmia analyzed the prevalence of depression using the BDI questionnaire (17).Overall, 68.1% of students had depression; of these, 19.3% had mild depression, 32.5% had moderate depression, and 16.4% had severe depression.The prevalence of depression in students was significantly related to age, parental education, parent's job, financial status, field of study, family income, and emotional behavior of parents with children (P < 0.05) (17).The percentage of students with severe depression in this study (16.4%) was higher than the percentage of students with severe depression in our study (6.09%).This may be due to differences of the two population samples in terms of age, because in the study of Rostamzadeh and Khalilzadeh, girls were of the menstruation age, which can affect mood and increase depression (18).In addition, they were closer to the age of puberty, which can be associated with dizziness, confusion, and pain resulting in hatred, which can affect mood and increase the probability of depression (19).
In 2013, Mortazavi et al. studied factors affecting depression, perceived stress, and perceived social support and their relationship with students living in dormitories at Shahid Beheshti University of Medical Sciences (10).Three hundred ninety men and women were randomly assigned to this study.Of these, 49.7% had different degrees of depression,

Table 1 .
Frequency of student demographic variables (Contd...)As shown in Table1, 278 (69.8%) participants were men and 120 (30.2%) were women.Three hundred fifty students (88%) lived in on-campus dormitories.A plurality of participants (35.6%) were from the medical faculty; 362 participants (91%) were single; and 333 participants (83.4 %) were non-native.(Actually students are divided into native or non-native who non-native students need dormitory to be placed.)Of the participants, 4% and 16.3% reported histories of alcohol use and smoking, respectively.Most students (73.6%) were in the 18-32 age group.Regarding college semester, 73.5% of students were studying during 1-3 semester.

Table 2 .
Frequency of depression among students

Table 3 .
Prevalence and relationship of depression according to studied variables