Assessing Medical Students Depressive Symptoms by Use of University Student Depression Inventory (USDI) in Sabzevar, Iran.

Document Type : Original Article


1 Sabzevar University of Medical Science, Sabzevar, IRAN.

2 Sabzevar University of Medical Science, Sabzevar, IRAN

3 Mashhad University of medical science, Mashhad, IRAN.

4 Department of Medical Education, Sabzevar University of medical science, Sabzevar, Iran.


Background: Many studies suggest depression rate in medical students is higher in comparison to others. Such disorder can cause motivation loss and hopelessness. Therefore, the aim of this study was to evaluate the depression symptoms and their contributors amongst medical students who were studying the Early Clinical Exposure (ECE) in Sabzevar, Iran.  
Methods: This cross-sectional study evaluated the students of Sabzevar University of Medical Science by applying University Student Depression Inventory (USDI) questionnaire, which was comprised of categories including lethargy, cognitive/environmental and academic motivation groups.
Results: Out of 75 students, 31 voluntarily completed the questionnaire. The mean total USDI score of participants was 60.71 ± 22.55. Although female students got higher USDI scores, data analysis did not show any significant association between USDI results and gender (p>0.05). Lethargy and academic motivation were significantly higher in 4th-semester students (p=0.04 and p=0.001 respectively) and Cognitive/emotional results were significantly higher in 7th semester (p=0.001).
Conclusion: Based on the results,  4th-semester students were experiencing more lethargy and showed less motivation for their courses. Reprogramming the ECE courses and providing medical students with more clinical exposure may reduce their depressive symptoms. In addition, 7th-semester students seem to experience more emotional problems which could be due to their upcoming clinical courses in few weeks.





University students are susceptible to various health problems. Depression is amongst these problems and according to World Health Organization (WHO) report, its general prevalence is about %5.1-3  As medical schools are considered stressful environments4, It is believed that medical students experience more depression and mental illnesses than the rest.4-8 Higher stress rates could be due to special exams, academic demands and increasing psychological pressure.9 Depression and anxiety, also, depend on various phases of medical education.10 As an example, first-year students suffer from separation from their families, dormitory problems or disorientation to the university environment that can lead to higher risk of depressive symptoms.11 Some studies suggest that during medical training the mental health of students can be deteriorated.12,13 Another reason could be the transition of medical students from basic science lessons to the clinical level.2 Poor motivation and emotional disorders can make medical students fail their courses and can lead to depression, as well. On the other hand, new educational methods seem to be designed to have profound effects on medical students’ motivation.14,10

Depression, as a relatively common disorder, is capable of affecting working performance and students’ personal lives.15 It could be presented by mood alteration and sadness. The symptoms can further change thinking, attitude and motivation. Most of these people will feel disabled later.16 Therefore, evaluation and in-time treatment of this illness and its symptom can protect many students from its harmful repercussions.

Although there might be much information about medical students’ depression in Iran, but there is not enough data referring to depressive-symptom rate in medical students who are educated with the new methods, such as early clinical exposure (ECE) method. It seems that implementation of ECE method can convert medical education courses to a more dynamic process. This method provides an early confrontation of medical students with patients before the beginning of their clinical courses and is responsible for medical stress.14  

Therefore, regarding the importance of depressive-symptom effects on medical students, and its dependence on different regional and educational methods, this study was conducted to evaluate those symptoms and the probable effects of new teaching methods on the mental health of the medical students of the Sabzevar University of Medical Science using a validated University Student Depression Inventory (USDI) questionnaire.



Study population:

This cross-sectional survey was conducted in Sabzevar University of Medical Science in 2012. The present research has been approved by Sabzevar University of Medical Science research committee (code number: 39201010/05). The only inclusion criterion for this study was being a medical student at any educational level. The only exclusion criteria in our study were incomplete form submission and 


the presence of any psychiatric disorder, described as taking any anti-depression medication within the last 6 months or any documented evidence of such. Fortunately, none of our participants suffered from those disorders. All the 75 medical students agreed to fill the questionnaire form voluntarily. After taking verbal consent and explaining the purpose of our study, the forms were given to students. However, only 31 students completely filled out the form. In each form the participants were asked to report their age, gender, years of study, marital status, grade point average and residency mode.

Study instruments:

University Student Depression Inventory (USDI) was used to evaluate the depressive symptoms among medical students; USDI is a 30-item test which measures student depressive symptoms. Participants had to answer how often they experienced each item in the past two weeks in a 5-point Likert scale from 1 “not at all” to 5 “all the time”. This test was shown to have strong positive relation with Depression Anxiety Stress Scales (DASS).17

It seems that students’ depression is somehow different from other people. For example, changes in sleep rhythms and appetite, which is asked in other depression questionnaires, can’t be beneficial in evaluation of their depressive symptoms, since these alterations can be made by students’ daily homework and duties. Other questionnaires seem to emphasize more on clinical aspects of depression and would be more helpful in determining students with severe rather than mild depression. USDI, on the other hand, seems to be better than other depression questionnaires due to the exclusion of some factors such as the above-mentioned topics, and paying more attention to the educational environment. Reliability and validity of the Persian version of the USDI questionnaire was assessed by Hejazi et al. (2007). This questionnaire proves to have an acceptable validity based on the Chronbach’s alpha analysis (Chronbach’s alpha was reported 0.93 for the overall scale while the value ranged between 0.83 and 0.94 for the sub-categories). The reliability was assessed using the Pearson correlation coefficient between two trials, which resulted in the r=0.86.18

Statistical analysis:

Descriptive statistics were used to identify mean and standard deviation of continuous variables. Independent t-test was used to compare USDI scores and cumulative grade point average (CGPA) among genders and 2nd-, 4th- and 7th-semester students. One way ANOVA was used to compare USDI and CGPS scores among mode of residence and semester categories regarding the normal distribution of data. Pearson correlation was used to identify the correlation between USDI score and CGPA. The confidence interval was considered as 95% and p values less than 0.05 were considered as statistically significant. Statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) program version 19.00.



A total of 31 medical students participated in the study. Among the participants, 12 students (38.7%) were in second semester, 10 (32.3%) and 9 (29.0%) students were studying in the 4th and 7th semester, respectively. Only one student was married and most of the students (74.2%) stayed


at the university dormitory.  Among the students who lived in the dormitory 11 were male and 12 were female, while 2 male and 3 female students lived in their houses. Mean cumulative grade point average (CGPA) of the students was 15.66 ± 1.09. Comparison of CGPA between study semesters and residence categories are illustrated in Table 1.

Mean total USDI score of participants was 60.71 ± 22.55. While mean score of females were higher than males, there was no significant difference in total USDI score between Male and female participants (p=0.84) or the semester (p=0.26) (Table 1). There was, either, no significant difference in term of USDI total score among the three study semester categories (p=0.34) (Table 1).

There was not any significant association between USDI 

questions’ results and gender (p>0.05). There was no significant correlation between USDI score and CGPA of study participants r(22)=0.11, p=0.62.

Moreover, there was no significant difference in terms of lethargy mean score amongst genders after running independent t-test (p=0.78). Lethargy scores were significantly higher among students in 4th-semester than 2nd and 7th-semesters. There was no significant difference in terms of cognitive/emotional mean score among genders after running independent t-test (p=0.60) (Table 2). Cognitive/ emotional mean score was significantly higher amongst students in 7th-semesters (Table 2), As well as academic motivation mean score amongst the ones in 4th-semester compared to 2nd- and 7th-semester students (Table 2).

Table 1. Comparison of participants’ USDI scores between gender, study semester and accommodation categories




USDI score



15.45 ± 1.24

78.08 ± 36.06


15.95 ± 0.79

81.00 ± 25.78

Statistical test

Independent t-test

t(20)=-1.07, p=0.30

t(29)=-0.64, p=0.53

Study semester


15.51 ± 0.67

55.83 ± 16.28


15.56 ± 0.72

108.86 ± 28.91


15.83 ± 1.54

67.22 ± 28.71

Statistical test

One way ANOVA

f(2, 19)=0.19, p=0.83

f(2, 28)= 1.11, p=0.34

Mode of residence


15.57 ± 1.18

85.93 ± 28.26


15.88 ± 0.64

72.20 ± 40.11


15.69 ± 1.56

60.00 ± 32.91

Statistical test

One way ANOVA

f(2, 21)=0.14, p=0.87

f(2, 30)= 0.46, p=0.63

Mean ± SD was shown for each category

Table 2. USDI factors mean scores and their comparison amongst study categories



Study semester

Mode of residence


















Statistical test

t(29)=-0.28, p=0.78†

f(2, 30)=3.41, p=0.04‡

f(2, 30)=0.40, p=0.67‡

Cognitive/ Emotion









Statistical test

t(29)=0.53, p=0.60†

f(2, 30)=19.21, p<0.001‡

f(2, 30)=0.67, p=0.52‡

Academic motivation

19.00 ±9.14








Statistical test

t(29)=1.13, p=0.27†

f(2, 30)=12.27, p<0.001‡

f(2, 30)=0.37, p=0.70‡

Mean ± SD was shown for each category

†Independent t-test was used for comparing values between categories

‡One way ANOVA was used for comparing values between categories


Depression is a multifactorial disorder which is under the influence of many other factors, such as university region, socio-economic status, parental education level and familial history.1 Medical universities had evaluated their students in various ways by various questionnaires. Turkey, Pakistan and united Kingdome reported higher levels of stress in 1st-year medical students while Tomas et al. claimed that 3rd- and 4th-year United States medical students are more depressed than those in the 1st and 2nd.19, 20 However, in a cross-sectional study conducted by Jadoon NA et al. in Pakistan on 815 medical students, higher anxiety prevalence was observed among 4th-, 6th- and 2nd-study semester students, respectively, which is in accordance with our results.21 Assadi et al. study reported a higher rate of psychiatric disorders among Iranian female medical students and doctors.22 The study by Tomas et al. also reported a higher rate of moderate and severe depression among female US medical students.23 These studies indicate that there is a higher levels of stress among female medical students. In another Iranian study on female students in Isfahan, mean total USDI score was 69.17±22.99, which was lower than our study. They didn’t evaluate medical students and also their study population was larger than ours.24  In Lee et al study, the mean total score of USDI for male and female students was 71.39±19.21 and 71.47±18.18 respectively, which are both lower than our study, but their first year students got higher mean total USDI score than our students (71.16±18.69 versus 55.83 ± 16.28 in our study). Apart from the effect of population size and students’ major, religion could be counted as another reason for our different results.25

Different educational methods and different depression evaluation tests in physiological studies make it hard to compare our results with other studies. Each medical university has its own unique environment and education board. The most effective factor about medical student depression, which seemed to be neglected, is the students’ exams and homework. Such factors make the comparison of various studies difficult. Different exams with different difficulty stages bring variable stress and depressive symptoms on each medical student. Preparation of 4th

semester students for their grand exam which takes place in the following year might be the reason of higher USDI scores in them. This effect vanishes in 7th-semester students, who have passed the exam a year ago. On the other hand, 7th-semester students will experience new clinical aspects of medical educations and feel closer to the clinical field. Some universities which are applying the integration program with ECE method may reduce this mental tension by integrating similar lessons and bring medical students earlier to clinical field from early semester.  Since depression in medical students affects their personal and educational lives, lack of new effective plans for this illness is still a problem. ECE and such programs can be beneficial for tackling this problem, but it needs further more comprehensive studies to evaluate depressive factors on medical students.

Identifying and paying special attention to depressive symptoms can promptly alleviate medical students’ further problems. According to our results, 4th-semester students are experiencing more lethargy and less motivation. By increasing their clinical exposure time we may further motivate them to become medical doctors and reduce the tedium of basic science lessons in their courses. By planning extra student-consulting lessons, we may also address 7th-semester students’ cognitive/emotional problems. However, further studies on larger populations, undergoing ECE methods, are required to evaluate the effect of depressive symptoms on students at different levels.

Study limitations:The major limitation of this study was the small sample size due to the small number of medical students who enrolled in the survey, as well as low response rate. Therefore, the results of this study might not be generalizable to the whole population of medical students. It is recommended that researchers conduct more comprehensive studies in numerous universities to achieve more reliable results.


Conflict of interest: We declare that here is no conflict of interest for the present study.

Funding and support: Sabzevar University of Medical Science has supported this study.

Research committee approval: The proposal of this research has been approved by Sabzevar University of Medical Science research committee (code: 39201010/05).


  1. Mergen H, Erdogmusmergen B, Tan Ş, Öngel K. Evaluating The Depression and Related Factors Among the Students of the Faculty of Education at Celal Bayar University. The New Journal of Medicine 2008;25: 169-174.
  2. Helmers KF, Danoff D, Steinert Y, Leyton M, Young SN. Stress and depressed mood in medical students, law students, and graduate students at McGill University. Acad Med. 1997 Aug;72(8):708-14.
  3. Psychiatr Epidemiol. 2008 Aug;43(8):667-72.

  4. Mosley TH Jr, Perrin SG, Neral SM, Dubber PM, Grothues CA, Pinto BM. Stress, coping, and well-being among third-year medical students. Acad Med. 1994;69:   765-7.

  5. Dyrbye LN, Thomas MR, Power DV, Durning S, Moutier C, Massie FS Jr, et al. Burn-out and serious thoughts of dropping out of medical school: a multi-institutional study. Acad Med. 2010; 85(1):94-102.

  6. Givens JL, Tjia J. Depressed medical students’ use of mental health services and barriers to use. Acad Med. 2002;77(9):918-921.


  7. Goebert D, Thompson D, Takeshita J, Beach C, Bryson P, Ephgrave K, et al. Depressive symptoms in medical students and residents:a multischool study. Acad Med. 2009;84(2):236-24

  8. Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad Med. 2006 Apr;81(4):354-73.

  9. Shaikh BT, Kahloon A, Kazim M, Khalid H, Nawaz K, Khan N, et al. Students, stress and coping strategies: a case of Pakistani medical school. Educ Health (Abingdon) 2004; 17: 346-53.


  10. Srivastava K, Raju B MSVK, Saldanha CD, Chaudhury CS, Basannar D, Pawar SC AA. Psychological Well-being of Medical Students. MJAFI 2007; 63 : 137-140

  11. Rafati F, Ahmadi J. Depression in Nursing Students of Shiraz University of Medical Sciences. JRMS 2004 Jan - Feb; 9(1):39-41.

  12. Miller P, Surtees P. Psychological symptoms and their course in first-year medical students as as-sessed by the Interval General Health Questionnaire(I-GHQ). Br J Psychiatry 1991;159:199-207.

  13. Amini M. Quality of life of medical students in different stages–A multi center study. J Med Educ 2009;11:13-9.

  14. Jafarzadeh Esfehani R, Kamranian H, Jafarzadeh Esfehani A, Rezaei Kalat A, Mahmudi Gharai A, Jalal Yazdi M. Effect of Early Clinical Exposure on Learning Motivation of Medical Students. FMEJ 2012; 2(2).

  15. Bitsika V, Sharpley C F, MelhemGender T C. Differences in Factor Scores of Anxiety and Depression among Australian University Students: Implications for Counselling Interventions. Canadian Journal of Counselling. 2010; 44(1): 51–64Lotfi MH, Aminian AH, Ghomizade A, Zarea S. Prevalence of Depression amongst Students of Shaheed Sadoughi University of Medical Sciences, Yazd, Iran. IRANIAN JOURNAL OF PSYCHIATRY AND BEHAVIORAL SCIENCES (IJPBS) Autumn and Winter 2010; 4(2):51-55.

  16. Shalini S, Geap OK., Harveen K O I S, Bakri S H S I, Baig M R, Dhanaraj S A. Study On The Prevalence Of Depression And The Impact Of Psychosocial Factors In Undergraduate Students At A Private University In Kedah, Malaysia. International Journal of Pharmaceutical Sciences and nanotechnology. 2011; 4(1): 1338-1346.

  17. Hejazi E,Sharifi A R,Shalchi B. Investigation of psychometric properties of university student depression inventory (USDI). PSYCHOLOGICAL STUDIES; Summer 2008; 4(2);125-149.

  18. Rab F, Mamdou R, Nasir S.Rates of depression and anxiety among female medical students in Pakistan. Eastern Mediterranean Health Journal. 2008; 14(1): 126-133. Schwenk TL, Davis L, Wimsatt LA.

  19. Depression, stigma, and suicidal ideation in medical students. JAMA. 2010 Sep 15; 304(11):1181-90.

  20. Jadoon NA, Yaqoob R, Raza A, Shehzad MA, Zeshan SC. Anxiety and depression among medical students: a cross-sectional study. J Pak Med Assoc. 2010 Aug;60(8):699-702.

  21. Assadi SM, Nakhaei MR, Najafi F, Fazel S. Mental health in three generations of Iranian medical students and doctors. A cross-sectional study. Soc Psychiatry Psychiatr Epidemiol. 2007 Jan;42(1):57-60.

  22. Mahajan AS. Stress in Medical Education: a global issue or Much Ado About Nothing specific? South‐East Asian Journal of Medical Education. 2010; 4(2): 9-13.

  23. . Rostami Z, Abedi MR. Standardization of student depression inventory in female university students in Isfahan. 2012 Fall; 13(4): 115-126.25. Lee RB, Maria MS, Estanislao S, Rodriguez C. Factors Associated with Depressive Symptoms among Filipino University Students. PLoS One. 2013 Nov 6;8(11):e7982