LITHUANIAN UNIVERSITY OF HEALTH SCIENCES
Health Psychology Department
Shir Tiger
Social, economical and lifestyle behaviors linked with depressive symptoms
appearance in international medical students.
Master’s Thesis
Thesis supervisor
Jevgenij Razgulin
Consultant Lect. Laura Sapranavičiūtė-Zabazlajeva PhD
TABLE OF CONTANT
1. SUMMARY ... 4
2. ACKNOWLEDGMENTS ... 6
3. CONFLICT OF INTEREST ... 7
4. CLEARANCE ISSUED BY THE ETHICS COMMITTEE ... 8
5. ABBREVIATION LIST ... 9
6. TERMS ... 10
7. INTRODUCTION ... 11
8. AIM AND OBJECTIVE OF THE THESIS ... 12
9. LITERATURE REVIEW ... 13
9.1 Depression and Depressiveness ... 13
9.2 Medical studies ... 14
9.3 Gender ... 15
9.4 Age ... 15
9.5 Life Style ... 15
9.6 Social and economical support ... 15
9.7 Language Skills ... 16 9.8 Summary ... 17 10. RESEARCH METHODOLOGY ... 18 10.1 Participants ... 18 10.2 Procedure ... 18 10.3 Instrument ... 18 10.4 Analysis ... 19 11. RESULTS ... 20 11.1 Depression ... 20
11.1.1 Depression and Faculty ... 21
11.1.2 Depression and Gender ... 21
11.1.3 Depression and Year, Age and BMI ... 22
11.1.4 Depression and Smoking ... 22
11.1.5 Depression and Drinking ... 23
11.1.6 Depression and Language Skills ... 24
11.1.7 Depression and Financial Support ... 25
11.2 Perceived Social Support ... 26
11.2.1 Perceived Social Support and Faculty ... 27
11.2.2 Perceived Social Support and Gender ... 28
11.2.3 Perceived Social Support and Year, Age and BMI ... 29
11.2.4 Perceived Social Support and Smoking Status ... 29
11.2.5 Perceived Social Support and Drinking Status and Frequency ... 30
11.2.6 Perceived Social Support and Language Skills ... 30
14. PRACTICAL RECOMMENDATIONS ... 37 15. REFERENCES ... 38
1. SUMMARY
Author: Shir Tiger
Title: Social, economical and lifestyle behaviors linked with depressive symptoms appearance in international medical students.
Aim: to evaluate the association between social, economical and lifestyle behaviors with depressive symptoms appearance in international medical students.
Objectives: 1) Assess depressive symptoms in international medical students. 2) Assessing for social and economical indicators such as age, gender, subject of studying, faculty, and lifestyle behaviors such as smoking, drinking, BMI and language skills. 3) Evaluate the association between depressive symptoms appearance with these factors in international medical students.
Methodology: the participants in this study were 101 students. The purpose of the study was to evaluate the appearance of depressiveness and to assess correlation to social, economical and lifestyle behaviors in international medical students. Only students that indicated that they are international students were enrolled. In the study we used Beck’s Depression Inventory to assess for depression and Multidimensional Scale of Perceived Social Support to assess for social support.
Results: gender and smoking have the highest association with depressive symptoms appearance among international medical students in Lithuanian University for Health and Science. Language skills after arriving to Lithuania and financial support had the highest association with social support among international medical students in Lithuanian University for Health and Science. All other factors such as age, faculty, subject of studying and life style, that were examined had no association between depression and depressive symptoms and social support.
Conclusion: there was an increased risk for depression in those who smoke and female gender, and an decreased social support in those with no financial support and in increased social support in those with better English knowledge after coming to Lithuania.
Practical recommendations: we would like to recommend the university to implant a program for mental health services that is both accessible and affordable. Elaboration of the existing mentoring program, in a way that will include higher years at the university as well, is recommended as well.
1. SANTRAUKA
Autorius: Shir Tiger
Pavadinimas: Tarptautinių medicinos studentų socialinės, ekonominės elgsenos ir gyvensenos sąsajos su depresijos simptomų pasireiškimu.
Tikslas: įvertinti tarptautinių medicinos studentų socialinės, ekonominės ir gyvensenos elgsenos sąsajas su depresijos simptomų pasireiškimu.
Uždaviniai: 1) Įvertinti tarptautinių medicinos studentų depresijos simptomus. 2) Įvertinti socialinius, ekonominius veiksnius, tokius kaip amžių, lytį, studijuojamą dalyką, fakultetą taip pat gyvensenos veiksnius, tokius kaip rūkymą, alkoholio vartojimą, KMI ir kalbos įgūdžius. 3) Įvertinti medicinos studentų depresijos simptomų pasireiškimo sąsajas su minėtais veiksniais.
Metodologija: šiame tyrime dalyvavo 101 studentas. Šio tyrimo tikslas buvo įvertinti depresyvumo pasireiškimą ir sąsajas su socialine, ekonomine ir gyvensenos elgsena. Į tyrimą buvo įtraukti tik tie studentai, kurie nurodė, kad yra tarptautiniai studentai. Tyrime depresijai nustatyti buvo panaudotas Beck‘o depresijos klausimynas, o socialiniam palaikymui įvertinti buvo panaudota Multidimensinė suvokiamo socialinio palaikymo skalė.
Rezultatai: lytis ir rūkymas turi didžiausias sąsajas su depresijos simptomų pasireiškimu tarp tarptautinių medicinos studentų Lietuvos sveikatos mokslų universitete. Kalbos įgūdžiai po atvykimo į Lietuvą ir finansinė parama buvo labiausiai susiję su socialiniu palaikymu tarp Lietuvos sveikatos mokslų universiteto tarptautinių medicinos studentų. Visi kiti tirti veiksniai, tokie kaip amžius, fakultetas, studijuojamas dalykas ir gyvensena nebuvo susiję su depresija ar depresijos simptomais bei socialine parama.
Išvados: padidėjusi depresijos rizika buvo stebima tų studentų, kurie rūkė ir kurie buvo moteriškos lyties, taip pat mažesniu socialiniu palaikymu pasižymėjo tie studentai, kurie turėjo mažesnę finansinę paramą, o didesnį socialinį palaikymą turėjo tie, kurių anglų kalbos žinios po atvykimo į Lietuvą buvo geresnės. Praktinės rekomendacijos: rekomenduotume universitetui diegti psichikos sveikatos pagalbos teikimo programas, kurios būtų lengvai pasiekiamos ir prieinamos. Išplėsti dabar esančią mentorių programą taip, kad ji apimtų ir vyresniųjų kursų studentus.
2. ACKNOWLEDGMENTS
I would like to thank the participants in the survey who supported my work and helped me getting high quality results. I am also grateful to Jevgenij Rezgulin, for his patience and support in overcoming numerous obstacles I was facing throughout my research. I would like to thank Juste Lukoseviciute for her feedback and cooperation with the statistics in the study. I am also grateful to Chia Tiger for helping me organizing my paper. I would like to thank my friends for expecting me to be nothing less than
excellence. I would like to thank my family for supporting me spiritually now and forever. Lastly, I would like to express my great appreciation to my partner in life, Yizhaq Lan who is experiencing with me this special and powerful journey of being a medical student. Thank you.
3. CONFLICT OF INTEREST
4. CLEARANCE ISSUED BY THE ETHICS COMMITTEE
5. ABBREVIATION LIST
MMD- major depressive disorder BDI- Beck’s Depression Inventory
MSPSS- Multidimensional Scale of Perceived Social Support BMI- Body Mass Index
6. TERMS
7. INTRODUCTION
Major depressive disorder (MDD) is the most common mental health disorder worldwide, affecting more than 300 million people of all age groups. It is the leading cause of disability and global burden of disease (WHO, 2012). The signs and symptoms of depression are changes in mood, usually characterized by melancholia and sadness, and a loss of interest that persists for more than two weeks. There are additional signals of depression such as loss of affect, suicidal thoughts and other behavioral changes.
Students studying across cultural borders is very common [1] in all area of academy, but in medical school it is the most common. Foreign students in Lithuania are as much as 4711 [2], with many of them in medical school, such as LSMU. Mental changes, and especially MDD and depressive disorder in international students is a subject that was widely researched in countries around the world in the past. In a study conducted in Australia, a direct correlation was found between studying abroad and depressive and mental changes. Moreover, they discovered that international students seek help less frequently which limits the diagnosis and prognosis if their depression [3]. The shock that the students feel upon arriving in a new country, directly affects their ability to adapt.
The development of MDD and depressive disorders, not only in international medical students, is influenced by several factors such as age, gender, appearance, financial support, social support, diet [4], smoking and drinking [5]. The influence of these factors cannot only be associated with depression and mental health issues, but it can also predicts the development of MDD and depressive disorders. Xiao at al. proved that obesity and poor physical activity are associated with increased risk of developing MDD and other mental changes, whereas good physical activity and good nutrition can decrease the risk of depression.
In this research, we will try to prove the correlation between depressiveness in international medical students and the influence of factors such as age, gender, social and financial support, appearance, diet, smoking and drinking.
8. AIM AND OBJECTIVE OF THE THESIS
Aim: to evaluate an association between social, economical and lifestyle behaviors with depressive symptoms appearance in international medical students.
Objectives:
1) Assess depressive symptoms in international medical students.
2) Assessing for social and economical indicators such as age, gender, subject of studying, faculty, and lifestyle behaviors such as smoking, drinking, BMI and language skills. Evaluate the association between depressive symptoms appearance with these factors in international medical students.
Our study will attempt to evaluate association between factors such as age, gender, subject of studying, faculty, social and economical support, lifestyle and language skills with depression and depressive symptoms among international medical students.
9. LITERATURE REVIEW
9.1 Depression and Depressiveness
Disorders of mood, sometimes referred to as affective disorder, are one of the primary categories of psychiatric illnesses such as depressive disorder, bipolar disorder and others. Many words are used to describe mood sad, depressed, apathy, melancholic and empty. They all describe the nature of depression. Moods can fluctuate and alternate rapidly. Changes in activity level, cognitive ability, speech, and vegetative function (sleep, appetite, sexual activity etc.) are also signs of MDD. This almost always results in impaired social, occupational and interpersonal function. Many will consider a disorder of mood as continuum of normal mood variation. Mood disorder patients, however, often report an ineffable, but distinct, quality of their pathological state [6].
A major depressive disorder occurs without a history of a manic, mixed, or hypomanic episode. An episode must last at least two weeks. Typically a person with a diagnosis of a major depressive episode also experiences at least four symptoms including changes in appetite and weight, changes in sleep and activity, lack of energy, feelings of guilt, problems thinking and making decisions, and recurring thoughts of death or suicide [6].
An additional mood disorder, dysthymic disorder has also been appreciated clinically for some time. Dysthymic disorder is characterized by the presence of symptoms that are less severe than those of major depressive disorder. It is characterized by at least two years of depressed mood that is not sufficiently severe to fit the diagnosis of major depressive episode [6].
Students studying across cultural boundaries is a well known costume science the days of World-War II. The effects of the cultural and behavioral changes in students is a subject that has been previously studied [1]. The challenges that the foreign student deals with are threefold. First, the stress that one experiences by moving to a new country including a new language, weather, loneliness, discrimination, homesickness, fear, guilt and misunderstandings [1] [3]. Second, the difficulties that adolescents face in the beginning of their study, managing alone in new environment while still in their stage of personality development. Third, the social stressors of being different in a new society. Therefore, it is not surprising that may of them suffer from poor mental health conditions such as depression and anxiety [1] [7].
The “foreign student syndrome” is described as a vague physical complaint, a passive withdrawal attitude and general disheveled appearance. Students who study abroad tend to “somatize” their problems in order to avoid the shame of having psychological and psychiatric complaint. This is supported by previous studies that show the association between migration and increase in somatic complaints, such as- digestive, dermatological and sexual. This theory is still being challenged of because the correlation between the medical care and cultural differences of the care giver and the patient [1].
Relocating to a different country is not the only risk factor that can be linked to having mental issues while living abroad. Sex, age, marital status and educational level also play an important role. They are all indicators of mental maturity and a developed and stable personality [8]. Some research shows that prior knowledge of the local language and manners ease the sojourners life [7] [9] [10].
Suicide is the fourth leading cause of death among young adults (Centers for Disease Control and Prevention, 2006). Depression is the most common risk factor for suicide, along with an adverse life event, substance abuse, family history, sexual abuse, identity disorders and troubled relationships. A study conducted in 2008 shows that 11% of students worldwide currently have suicidal ideation. The study also found that they were all screened positively for depression [11]. According to Mackenzie et al., 10% of females and 13% of males had thoughts of killing themselves. Male and female students with a history of emotional abuse were significantly more likely to be depressed than were students who did not report abuse [12]. Studies linked it to work overload, competitive environment, constant pressure, and the studies themselves, as well as the need to deal with traumatic events, ethical dilemmas, cadaver dissection, fear of acquiring diseases, first physical examination and medical hierarchies [13].
9.2 Medical studies
Depression and anxiety that international students experience are not only related to the fact that they are foreigners, it is associated with the subject they choose to study. Medicine is a challenging academic carrier. The majority of stress and depressive symptoms that the students feel is primarily in the first two years leading up to the degree [14]. When compared to general students population, it was found that medical students have a higher risk for depression [15]. Medical students are highly prevalent to
9.3 Gender
Regarding the appearance of depression and depressive symptoms in international students, there are disagreements. Some studies show that female students have no correlated between social support and the developments of depression and depressive symptoms. Other found that female students with higher levels of social support had lower levels of depression and depressive symptoms. The gender difference in these studies could be due to the cultural and social background [10] [16].
9.4 Age
Mental health issues are becoming an increasingly common worldwide and present a major public health concern. Ten to 44 percent of people suffer from depression and anxiety worldwide. Compered to the total population, people at ages 16-44 years have higher risk of having depression. In a study conducted on international students in united states, it was shown that younger students have lesser probability of having anxiety and depression compared to older students. It was attributed to the ease in accepting changes at a younger age then older [10].
9.5 Life Style
Life style such as smoking, drinking and dietary habits were shown to have a great influence on the development of depression and depressive disorders. Compared to those who smoke it was found that they have increased risk for depression. The association of depression with obesity in the general population was measured. It was found that the greater the BMI, the worse the executive function [17][18][4]. When sedentary behavior was evaluated among the general population it was established that it increases the likelihood of having depression and anxiety [5].
9.6 Social and economical support
The ability to develop skills to manage everyday tasks and interact with others strongly influenced the wellbeing and subsequent mental health of these students. Many of them had not previously been independently responsible for their accommodation, transport, or general self-care. Managing part-time jobs and their own budgetary matters was particularly stressful, especially for those experiencing financial difficulties. Furthermore, without social support, international students were vulnerable to new-found freedoms for which they were often unprepared. As a result they were likely to experience associated stresses and depressive symptoms. It is thought that socialization with different nationalities can
dramatically reduce the psychological adjustment (loneliness/homesickness). It is suggested that socializing with those who share the same experiences can reduce the feeling of loneliness and contribute to a sense of belonging among the foreigners, decreasing the risk for depression and anxiety. Moreover, it is showed to increase the adaptation to the new situation [19]. There is one factor that serves to help overcome depression: closeness to family and friends. Studies show that the greater the feeling of loneliness the more significant the depression is. But for those who had more established and firm relationships with friends and family, the easier its was adjusting to the move to a new country [20]. Common experience among international students is loneliness. Medical students typically are removed from their social support when they begin studying abroad. They may feel as if they have less or fewer people to rely on. Researchers show that loneliness can lead to depression in the general population. It is important to have family support and good quality relationships with both other foreign students, as well as with the local students. The psychological effect on the mental health of the students is powerful and must be addressed [21]. The financial situation of a student also correlates with the level of depression. A study in the Philippines showed a direct association between the levels of satisfaction and the student’s ability to provide for him/her self. Older students with more responsibility showed increased frustration when having to rely on their parents financially [20].
9.7 Language Skills
Multiple studies conducted on different populations showed that those who had previous knowledge of the language had a softer acclimatization. Self-reported English language fluency was a significant predictor of acculturative distress. Specifically, higher frequency of use, fluency level, and the degree to which participants felt comfortable speaking English, predicted lower levels of acculturative distress among international students. This finding is associated with the fact that higher English fluency may be related to smoother interactions with the majority group members. One may be able to interact with greater ease with people in this new cultural setting. This may lead to increased feelings of adjustment. In addition, international students with higher self-reported levels of English language fluency may be less embarrassed and less self-conscious about their accent or ethnic background. They may be able to interact with more confidence in their daily lives. Finally, higher levels of English language fluency could help international students perform at a higher level in some academic classes since they
9.8 Summary
When comparing a more closely related populations - local students to international students, it was found that the international students suffered more from depressive symptoms then students in other faculties. It is suggested that all participants identified numerous interrelated challenges faced by international students in the early stages of their sojourn, and these were commonly and collectively referred to as ‘culture shock’. This multifaceted notion involved adjustment to a different academic system and adaptation to new and diverse cultural norms. Much of the discussion related to the student groups that are culturally different from the country they chose to study in. These groups in particular tended to face major challenges associated with language and unfamiliar methods of teaching, learning and teacher-student interactions [3]. Although the literature regarding the presence of depression among medical students is abundant, it is difficult to distinguish it from the effect of stress in student’s life [13]. In this study we will demonstrate the correlations between these factors and the development of depressive symptoms and depression. In this study will try to demonstrate the correlation, either positive or negative, between the subjects of gender, age, life style, socioeconomic status and language skills, with the development of depression and depressive symptoms among international medical students.
10. RESEARCH METHODOLOGY
10.1 Participants
The participants in this study were 101 students. Medicine (n=78), veterinary (n=3), odontology (n=16), pharmacy (n=2) and occupational therapy (n=1) studying in LSMU. The purpose of the study was to evaluate the appearance of depressiveness and correlate it to physiopsychological factors in international medical students. Only students that indicated that they are international students were enrolled. To qualify as an international student, the participant needed to indicated that they are part of the international program in LSMU.
10.2 Procedure
The survey was handed to students during their free time after studies. They were given ample amount of time to complete it. The participant did not know that the questions were regarding depression assessment, in order to be impartial, and avoid bias while felling the questioner. The survey was anonymous. Students were also informed that their results were not indicative of a clinical diagnosis, and if they were concerned about their results they should seek the advice of a qualified practitioner for further evaluation.
10.3 Instrument
The survey instrument comprised a number of demographic items and questions relating to students’ international student status, the year in which they are in, their English fluency before and after arriving to Lithuania, smoking and drinking status, gender, faculty, financial support, Beck’s depression scale and Multidimensional Scale of Perceived Social Support.
Beck’s depression inventory is a self-assessment survey composed of 21 items relating to symptoms of depression such as hopelessness and irritability, cognitions such as guilt or feelings of being punished, as well as physical symptoms such as fatigue, weight loss, and lack of interest in sex. The BDI
clinical depression. Forth, 21-30 is moderate depression. Fifth, 31-40 is severe depression. Sixth, over 40 is extreme depression.
Multidimensional Scale of Perceived Social Support is a self-assessment survey composed of 12 items relating to social, family and friends support. The MSPSS is widely used tool in psychological assessment. The participants need to mark how much they agree with the statement that is given, 1 if you Very Strongly Disagree, 2 if you Strongly Disagree, 3 if you Mildly Disagree, 4 if you are Neutral, 5 if you Mildly Agree, 6 if you Strongly Agree, 7 if you Very Strongly Agree. It is calculated by adding all the numbers and making an average. The final score is then grouped into 3 groups. First group 1-2.9, low support. Second 3-5, medium support. Third group 5.1-7, high support.
10.4 Analysis
Data were processed using MS Excel 2010 and analysed using IBM SPSS Statistics, version 23. Only completed surveys were included in the analysis. The descriptive analysis included the calculation of the prevalence, minimum, maximum and median. Categorical data were presented as percentages (n, %), continuous variables were presented as mean ± standard deviation (SD). Comparisons done using the Mann-Whitney U test and Spearman's rank correlation. The statistical significance level was set at 95%.
11. RESULTS
11.1 Depression
In order to determine the level of depression with relation to social and economical factors and lifestyle behaviors, the BDI was divided to 6 groups according to the severity. A detailed comparison of study groups by faculty, gender, risk behavior, English knowledge and financial support are presented in Table 1.1
Table 1.1 The main characteristics of study sample
Characteristic Mean Rank p value
Faculty 0.865 Medicine 50.68 Others 49.86 Gender 0.004 Male 47.58 Female 55.8 Smoking 0.003 Yes 61.87 No 47.7 Drinking 0.391 Yes 50.15 No 54.43 How often 0.615 At least once a month 40.99
At least once a week 42.74 English knowledge before
0.507
Native/ very good 52.39
Average/ poor 49.75
English knowledge after
0.702
Native/ very good 39.05
Average/ poor 37.26
Financial support
0.568
Yes 50.34
No 46.19
11.1.1 Depression and Faculty
When comparing BDI to measure the depressiveness of students among faculties, medicine (n=78, mean rank= 50.68) and all other faculties (n=22, mean rank=49.86), there was no statistically significant differences between depressiveness and faculty, p value is 0.865. Normal ups and downs (score 1-10) total n=79, among medicine students n=61, others n=18. Mild mood disturbance (score 11-16) total of n=11, medicine students n=8, others n=3. Borderline clinical depression (score 17-20) total of n=4, medicine students n=4, others n=0. Moderate depression (score 21-30) total n=3, medicine students n=2, others n=1. Sever depression (score 31-40) total n=1, medical students n=1, others n=0 (Figure 1.1).
Figure 1.1 Depressiveness & Faculty
11.1.2 Depression and Gender
Comparison of BDI to measure the level depressiveness of students with gender (male n=59 mean rank= 47.58, female n=42 mean rank=55.80), there was statistically significant differences between depressiveness and gender, females had higher probability of having depressive symptoms then males, p value= 0.041. Normal ups and downs (score 1-10) total participants n=82, male n=52, female n=30. Mild mood disturbance (score 11-16) total participants n=11, male n=3, female n=8. Borderline clinical depression (score 17-20) total participants n=4, male n=3, female n=1. Moderate depression (score 21-30) total participants n=3, male n=1 female n=2. . Sever depression (score 31-40) total participants n=1, male n=0 female=1 (Figure 1.2). 0.00% 20.00% 40.00% 60.00% 80.00% 100.00% 1-10 11-16 17-20 21-30 31-40 >40 Medicine Others
Figure 1.2 Depressiveness & Gender
11.1.3 Depression and Year, Age and BMI
The correlation between depressiveness of students with Year, Age and BMI shown in Table 1.2.
Table 1.2
Year Age BMI
p value 0.987 0.096 0.383
r 0.002 0.167 0.088
As seen in the table, there are no correlations between year, age and BMI with depression and depressive symptoms.
11.1.4 Depression and Smoking
Comparing BDI to measure the depressiveness of students with smoking status (yes n=23, mean rank= 61.87; no= 78, mean rank= 47.79), there was statistically significant differences between depressiveness and smoking, those who smoke had a higher risk of being depressed then those who did not smoke, p value= 0.003. Normal ups and downs (score 1-10) total of n=82, smokers n=14, nonsmokres n=68. Mild mood disturbance (score 11-16) total of n=11, smokers n=4, nonsmokers n=7. Borderline clinical depression (score 17-20) total of n=4, smokers n=2, nonsmokers n=2. Moderate depression (score 21-30) total of n=3, smokers n=2 nonsmokers n=1. Sever depression (score 31-40) total of n=1 scored, smokers n=1, nonsmokers=0 (Figure 1.3).
0.00% 20.00% 40.00% 60.00% 80.00% 100.00% 1-10 11-16 17-20 21-30 31-40 >40 male female
Figure 1.3 Depressiveness & Smoking
11.1.5 Depression and Drinking
Compering BDI to measure the depressiveness of students with drinking status (yes n= 81 mean rank=50.15; no n=20 mean rank= 54.43), there was no statistically significant differences between depressiveness and drinking status, p value= 0.391. Normal ups and downs (score 1-10) total of n=82 scored 1-10, n=67 drink, n=15 do not drink. Mild mood disturbance (score 11-16) total of n=11, n=9 drink, n=2 do not drink. Borderline clinical depression (score 17-20) total of n=4, n=2 drink, n=2 do not drink. Moderate depression (score 21-30) total of n=3, n=2 drink, n=1 do not drink. Sever depression (score 31-40) total of n=1, drink n=1, n=0 do not drink. The amount of drinks was n=83, at least once per month n=35 mean rank= 40.99, at least once a week n=48 mean rank= 42,74, there was no statistically significant differences between depressiveness and amount of drinks p value is 0.615. Normal ups and downs (score 1-10) total of n=69, n=30 drink once per month, n=39 drink at least once a week. Mild mood disturbance (score 11-16) total of n=9, n=3 drink at least once a month, n=6 drink at least once a week. Borderline clinical depression (score 17-20) total of n=2, n=1 drink at least once a month, n=1 drink at least once a week. Moderate depression (score 21-30) total of n=2, n=1 drink at least once a month, n=1 drink at least once a week. Sever depression (score 31-40) total of n=1, drink at least once a month n=1, drink at least once a week n=0 (Figure 1.4, Figure 1.5).
0.00% 20.00% 40.00% 60.00% 80.00% 100.00% 1-10 11-16 17-20 21-30 31-40 >40 Smoking Not smoking
Figure 1.4 Depressiveness & Drinking
Figure 1.5 Depressiveness & Frequency of Drinking
11.1.6 Depression and Language Skills
When comparing the English fluency after coming to Lithuania with BDI to measure the depressiveness of students, n=48, mean rank=52.39 reported knowing English native/ very good, n=53 mean rank 49.75 reported knowing English average/ poor, there was no statistically significant differences between depressiveness and English knowledge after coming to Lithuania, p value= 0.507. Normal ups and downs (score 1-10) total of n=82, n=62 reported native/ very good, n=20 reported average/ poor. Mild
0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00% 1-10 11-16 17-20 21-30 31-40 >40 Drink Not drinking 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00% 1-10 11-16 17-20 21-30 31-40 >40 At least once a month At least once a week
n=1 reported average/ poor. Sever depression (score 31-40) total of n= 1, n=1 reported native/ very good, n=0 reported average/ poor. When compering the English fluency before coming to Lithuania with BDI n=74, mean rank= 49.60 reported knowing English native/ very good, n=26 mean rank 53.06 reported knowing English average/ poor, there was no statistically significant differences between depressiveness and English knowledge before coming to Lithuania, p value=0.435. Normal ups and downs (score 1-10) total of n=82, n=38 reported native/ very good, n=44 reported average/ poor. Mild mood disturbance (score 11-16) total of n=11, n=4 reported native/ very good, n=7 reported average/ poor. Borderline clinical depression (score 17-20) total of n= 4, n=3 reported native/ very good, n=1 reported average/ poor. Moderate depression (score 21-30) total of n=3, n=2 reported native/ very good, n=1 reported average/ poor. Sever depression (score 31-40) total of n= 1, n=1 reported native/ very good, n=0 reported average/ poor (Figure 1.6).
Figure 1.6 Depressiveness & Language Fluency (before and after arriving to Lithuania)
11.1.7 Depression and Financial Support
Compering BDI to measure the depressiveness of students with the reported financial support n=91 reported receiving financial support, mean rank = 50.34, n=8 reported not receiving financial support, mean rank= 46.19, there was no statistically significant differences between depressiveness and financial support, p value 0.568. Normal ups and downs (score 1-10) total of n=81, n=73 reported financial support, n=7 reported no support. Mild mood disturbance (score 11-16) total of n=11, n=10 reported financial support, n=1 reported no support. Borderline clinical depression (score 17-20) total of
0.00% 20.00% 40.00% 60.00% 80.00% 100.00% 1-10 11-16 17-20 21-30 31-40 >40 Average/ Poor After Native/ Very good After Average/ Poor Before Native/ Very good Before
n=3, n=3 reported financial support, n=0 reported no support. Sever depression (score 31-40) total of n=1, n=1 reported financial support, n=0 reported no support (Figure 1.7).
Figure 1.7 Depressiveness & Financial Support
11.2 Perceived Social Support
In order to investigate the level of social and emotional support we used the Multidimensional Scale of Perceived Social Support and correlated them with social and economical factors and lifestyle behaviors. The scale is divided to 3 groups, each indicating the level of support perceived by the participants. A detailed comparison of study groups by faculty, gender, risk behavior, English knowledge and financial support are presented in Table 1.3
0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00% 1-10 11-16 17-20 21-30 31-40 >40 Yes No
Table 1.3 The main characteristics of study sample
Characteristic Mean Rank p value
Faculty 0.991 Medicine 50.49 Others 50.55 Gender 0.361 Male 49.29 Female 53.40 Smoking 0.503 Yes 48.26 No 51.81 Drinking 0.126 Yes 52.69 No 44.15 How often 0.375 At least once a month 43.97
At least once a week 40.56 English knowledge before
0.277
Native/ very good 48.46
Average/ poor 53.30
English knowledge after
0.031
Native/ very good 53.34
Average/ poor 42.40
Financial support
0.02
Yes 51.51
No 32.81
When comparing the study groups we found a statistical difference between Perceived Social Support and English knowledge after coming to Lithuania and between Perceived Social Support and financial support. Those with better knowledge of English after arriving to Lithuania had more social support and those with no financial support had less social support.
11.2.1 Perceived Social Support and Faculty
When comparing Perceived Social Support with faculty, n=78 mean rank= 50.49 were medicine students and n=22 mean rank=50.55, there was no statistically significant differences between Perceived Social Support and Faculty, p value is 0.991. Low support (score 1-2.9) total of n=5, n=5 are from medicine faculty, n=0 are from other faculties. Medium support (score 3-5) total of n= 21, n=15 are from
medicine faculty, n=6 are from other faculties. High support (score 5.1-7) total of n=74, n=58 are from medicine faculty, n=16 from other faculties (Figure 1.7).
Figure 1.7 Perceived Social Support & Faculty
11.2.2 Perceived Social Support and Gender
Comparison of Perceived Social Support with gender, n=59 mean rank 49.29 are males, n=42 mean rank= 53.40 are females, there was no statistically significant differences between Perceived Social Support and Gender, p value is 0.361. Low support (score 1-2.9) total of n=5, n=4 are males, n=1 female. Medium support (score 3-5) total of n=21, n=13 are males, n=8 are females. High support (score 5.1-7) total of n=75, n=42 are males, n=33 are females (Figure 1.8).
Figure 1.8 Perceived Social Support & Gender
0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00% 1-2.9 3-5 5.1-7 Medicine Others 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00% Male Female
11.2.3 Perceived Social Support and Year, Age and BMI
The correlation between Perceived Social Support with Year, Age and BMI (Table 1.4)
Table 1.4
Year Age BMI
p value 0.518 0.766 0.311
r 0.065 0.030 0.102
As seen in the table, there are no correlations between year, age and BMI with perceived social support.
11.2.4 Perceived Social Support and Smoking Status
Compering Perceived Social Support with smoking status, n=23 mean rank= 48.26 do smoke, n=78 mean rank= 51.81 are non smokers, there was no statistically significant differences between Perceived Social Support and Smoking Status, p value of 0.503. T Low support (score 1-2.9) total of n=5, n=2 are smokers, n=3 are non smokers. Medium support (score 3-5) total of n=21 scored 3-5, n=5 are smokers, n-16 are non smokers. High support (score 5.1-7) total of n= 75, n=16 are smokers, n=59 are non smokers (Figure 1.9).
Figure 1.9 Perceived Social Support & Smoking Status
0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00% 1-2.9 3-5 5.1-7 Smokeing Not Smoking
11.2.5 Perceived Social Support and Drinking Status and Frequency
Compering Perceived Social Support with drinking status, n=81 mean rank = 52.69 drink, n=20 mean rank=44.15 do not drink, there was no statistically significant differences between Perceived Social Support and Drinking Status and Frequency, p value is 0.126. Low support (score 1-2.9) total of n=5, n=4 are drink, n=1 are not drinking. Medium support (score 3-5) total of n=21, n=14 drinks, n-7 are not drinking. High support (score 5.1-7) total of n= 75, n=63 drinks, n=12 are not drinking. Low support (score 1-2.9) total of n=4, n=1 drink at least once a month, n=3 drinks at least once a week. Medium support (score 3-5) total of n=14, n=5 drink at least once a month, n=9 drinking at least once a week. High support (score 5.1-7) total of n= 65 scored 5.1-7, n=29 drink at least once a month, n=35 drinking at least once a week (Figure 1.10, Figure 1.11).
Figure 1.10 Perceived Social Support & Drinking
Figure 1.11 Perceived Social Support & Drinking Frequency
0.00% 20.00% 40.00% 60.00% 80.00% 100.00% 1-2.9 3-5 5.1-7 Drinking Not Drinking 0.00% 20.00% 40.00% 60.00% 80.00% 100.00% 1-2.9 3-5 5.1-7 At least once a month At least once a week
average/ poor levels, there was no statistically significant differences between Perceived Social Support and Language Skills before coming to Lithuania, p value is 0.277. Low support (score 1-2.9) total of n=5, n=2 knew English as native/ very good, n= 3 knew English average/ poor. Medium support (score 3-5) total of n=21, n=13 knew English as native/ very good, n= 8 knew English average/ poor. High support (score 5.1-7) total of n=75, n=33 knew English as native/ very good, n= 42 knew English average/ poor. Comparison of Perceived Social Support and language skills after arriving to Lithuania, n=74 mean rank= 53.34 knew English language native/ very good levels, n=26 mean rank=42.40 knew English average/ poor levels, there was statistically significant differences between Perceived Social Support and Language Skills after coming to Lithuania, those with higher levels of English knowledge after coming to Lithuania had higher social support, p value is 0.031. Low support (score 1-2.9) total of n=5, n=3 knew English as native/ very good, n=2 knew English average/ poor. Medium support (score 3-5) total n=21, n=12 knew English as native/ very good, n=9 knew English average/ poor. High support (score 5.1-7) total n=75, n=59 knew English as native/ very good, n=16 knew English average/ poor (Figure 1.12).
Figure 1.12 Perceived Social Support & Language Skills
11.2.7 Perceived Social Support and Financial Support
When compering MSPSS with financial support n=91 mean rank= 51.51receive financial support, n=8 mean rank= 32.81 do no receive financial support, there was statistically significant differences between Perceived Social Support and Financial Support, those with financial support had a higher levels of social support, p value is 0.02. Low support (score 1-2.9) total of n=5, n=4 receive support, n=1 is
0.00% 20.00% 40.00% 60.00% 80.00% 100.00% 1-2.9 3-5 5.1-7 Average/ Poor After Native/ Very good After Average/ Poor Before Native/ Very good Before
missing. Medium support (score 3-5) total of n=21, n=16 receive financial support, n=5 do not receive. High support (score 5.1-7) total of n=75, n=71 receive financial support, n=3 do not receive financial support, n=1 is missing (Figure 1.12).
Figure 1.12 Perceived Social Support & Financial support
11.3 Depressiveness and Perceived Social Support
The correlation between depressiveness (BDI) and Perceived Social Support (Table 1.5, figure 1.13). Table 1.5 p value r Depressiveness vs. Perceived Social Support 0.109 0.161
Figure 1.13 DBI & MSPSS
0.00% 20.00% 40.00% 60.00% 80.00% 100.00% 1-2.9 3-5 5.1-7 Yes No
0 1 2 3 4 5 6 0 0,5 1 1,5 2 2,5 3 3,5 Be ck Social support
As seen in table 1.5 and figure 1.13, there are no correlations between depression or depressive symptoms to perceived social support.
12. Discussion of the results:
We investigated to what extent international students’ faculty, age, gender, English skills, life style (smoking, drinking and BMI), financial support, and social support to predict the development of depression and depressive symptoms. According to our results, faculty has no difference in depressive symptoms or in social support. Although, this study was conducted in the different departments in LSMU (medicine, odontology, veterinary, pharmacy and physiotherapy), other studies show that students who study medicine have higher risk of experiencing depressive symptoms [16]. The gender parameter showed a different association, depressiveness had an association between males and females. Females had a much higher risk of developing depressive symptoms then males [10] [20]. According to social support there is no association between the genders in our research. Although other researchers contradict this findings [10] [22] [20], others support this finding and also indicate that there is association between social support and female gender [14] [16]. Although there are studies showing that there is a correlation between the progression in years in the university and the development of depression and depressive symptoms and to social support [8], our study did not find correlation with depressive symptoms or with social support, it is supported by another study that shows that there is no difference in depressive symptoms and year [20]. There is no correlation between the depressive symptoms and age in our study or with social support, this is supported by a study showing that there is no correlation between age and depressive symptoms or social support[20]. Other studies showed that younger students have less depression then older [10]. There are no current studies that investigated the correlation between the life style, such as, smoking, drinking and dietary habits (BMI) of the international students and the development of depressive symptoms, but in studies conducted in the general population it is shown this factors are highly associated with the development of depression and depressive disorders [5] [18]. When we compered smoking and depressive symptoms we found a significant difference between those who smoke and those who do not, those who smoke have a higher risk of developing depressive symptoms, however there is no difference in the social support and smoking status. We did not find correlation between BMI and depressive symptoms or social support. When we compered drinking status and the frequency of drinking we found no difference in both depressiveness and social support. In our study we investigated the difference between the levels of English skills/ fluency before and after arriving to
skill after arriving to Lithuania. This is not supported by other studies investigating the same subject [10], the difference is that in our study we investigated the difference between the English skills before and after moving to Lithuania. Although studies have showed that there is difference in the depressive symptoms and social support [20], we could only show the difference between social support and financial support, those with higher financial support have a greater social support. There is no significant difference between the development of depressive symptoms and financial support. There are much studies that support the correlation between the development of depressive symptoms and social support [10] [16] [14] [9], in our study we could not show the negative correlation between depressiveness and social support.
13. CONCLUSION
Our study focused on the mental well being of international students in medicine faculty and other faculties in LSMU. We investigated the development of depression and depressive symptoms and the social support in relation to social, economical factors and lifestyle behaviors.
We tried to recognize the factors that may contribute to the development of depression or depressive symptoms. We investigated these factors and we conclude that depression is a statistically difference with gender; females have a much higher tendency of developing depressive symptoms as opposed to males. When we compered modifiable factors such as smoking, we found that international students that smoke have a higher association with developing depression or depressive symptoms.
The correlation of social support was investigated as well in relation to the same factors. We demonstrated significant difference between social support and English skills after arriving to Lithuania and financial support. Those with better English skills have greater social support. Those with financial support feel more supported by their friends and family.
All other factors such as age, faculty, subject of studying, although the results of many of the other studies showed correlations between depressiveness and social support with the factors our study examined, we could not find a statistical significant and difference. We can propose to make a larger and more diverse group to increase to chance of receiving statistical significant results.
14. PRACTICAL RECOMMENDATIONS
International students commonly delayed seeking help for mental health problems until it is too late to receive the adequate care that would enable them to successfully complete their studies. These situations often produced experiences of shame, brought about in part by the complexities of negotiating a culturally different health system. It is believed that students often treated mental health and emotional issues as physical health problems. These dynamics could contribute to the rising incidence and severity of mental health issues among international students. It calls for early intervention to ameliorate the delay in seeking help, which tends to escalate the seriousness of the problems and the likelihood of fragmented care.
In light of the findings in this study, we would like to recommend the university to implant policies of mental health services for international students, which are accessible and affordable. This includes both, private consultations and special programs, where students can get their emotional and social support not only from trained university personal, such as psychologists, but also from their fellow students. As for now, this kind of program exists only for fist year students. We would like to recommend elaborating the program also to higher years. We would also like to recommend a change in life style across university campuses. To minimize the areas where it is allowed to smoke, making the food healthier in the university cafeterias. Adding sport activities across the university campuses such as dancing, football, basketball and swimming. This will support the students’ physical health and thus increasing their mental strength.
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