Assessment of Mental Health Literacy of Depression and Suicide among Undergraduate Medical Students: A cross-sectional study

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The Arab Journal of Psychiatry (

) Vol. 31 No.2 Page (159 – 168) (doi-10.12816/0056867)
Assessment of Mental Health Literacy of Depression and Suicide among Undergraduate Medical
Students: A Cross-Sectional Study
Eman Elsheshtawy, Miriam Simon, Sirous Golchinheydari, Jawaher Al Kharusi
 
Abstract
ackground: Poor literacy of depression and suicide can be considered a key barrier for help seeking in mental
health issues. Objective: The current study aimed to assess the differences in depression and suicide literacy
among medical students in the pre-medical level (2nd and 3rd year) and clinical level (6th and 7th year); and, to
determine which factors predict higher levels of literacy. Methods: A cross-sectional study recruited 359 students who
were in the pre-medical and clinical years. Measures included a socio-demographic questionnaire, the Depression Literacy
Questionnaire (D-Lit), and the modified Suicide Literacy Scale (LOSS). Results: Clinical years’ students appear to have
higher depression and suicide literacy (z=8.343, p=.001; z=4.563, p=.001), respectively. High depression literacy predicted
higher suicide literacy (beta=.356, p=0.001) while previous exposure to psychiatric patients predicted higher depression and
suicide literacy (beta=.172, p=.022; beta=.175, p=.032, respectively). Conclusion: There remains an urgent need to design
and implement specific educational programs to improve awareness about depression, suicide and mental health in general
starting at the highschool level of education.
Key words: medical students, depression literacy, suicide literacy, Oman
Declaration of interest: None
Introduction
Depression is a common mental health problemand the
leading cause of mental health related disease burden
globally. There is evidence to suggest that onset occurs
in adolescence; that it can be recurrent; and, in severe
cases can lead to suicide.1 The prevalence of depressive
symptoms and suicidal ideation among medical students
is reported to be higher than in the general population.2
Students with an experience of depression may also
suffer from burnout, anxiety, suicidal thoughts and
substanceuse.3,4 Research describes deterioration of their
mental health during their medical education that
continues to decline even after graduation.5
The estimated prevalence rate of depressive symptoms
among medical students was 27.2% and that of suicidal
ideation was 11.1%, according to one meta-analysis; it is
also suggested that such symptoms were more common
in medical students than other undergraduates students of
similar age.6 Despite their being symptom improvement
as students become residents and medical professionals,
they are still more likely to experience depression and
distress across different stages of life. Previous studies in
Oman found the prevalence rate of depressive symptoms
among high school students was 17% while among
medical students it was approximately 11%.7,8 Although
mental health problems arising at a young age often
require early intervention, a high percentage of young
people do not seek help.9 Among the barriers to help
seeking are perceived stigma and low mental health
literacy in addition to an inability to recognize
symptoms.10
Depression and suicide literacy are aspects of mental
health that affect help-seeking behaviors and influence
treatment choices and compliance. Mental health literacy
refers to the knowledge and beliefs about mental health
conditions that help with recognition, management, and
prevention.11 Poor knowledge and understanding of
depression can be a key barrier that may prevent people
from seeking help for their mental health issues. It
follows that improving literacy among adolescentscan
result in positive gains for their mental health in later
life.12 Research on mental health literacy tends to be
conductedin mainly Western countries. A limited number
of studies in Arab countries have demonstrated poor
mental health knowledge.13,14,15 Most studies describe the
need for educational intervention starting at the high
school level, which can help decrease stigma and
improve knowledge.16
The aim of the current study is to evaluate differences in
the level of mental health literacy for depression and
B

Mental Health Literacy of Depression and Suicide
suicide among medical students in the pre-medical level
(2nd and 3rd year) and clinical level (6th and 7th year); and, to establish which factors may predict higher levels of
literacy.
Method
Design
A cross sectional study was conducted from September
2018 to March 2019 at two institutions of higher learning
in the Sultanate of Oman: College of Medicine and
Health Science andNational University of Science and
Technology. The student population is from Oman,
India, Iran, and Bangladesh, among other countries.
Participants
Participants were recruitedfrom pre-medical years (2nd
and 3rd) and clinical years (6th and 7th). Each year had
120 students apart fromthe final year, which had 110
students. From a total of 450 students, 359 joined the
study: 70 from the pre-medical years (2nd and 3rd) and
189 from clinical years (6th and 7th). Participants were
individually approached and recruited consecutively after
obtaining informed consent. Participants did not receive
any honorarium for their involvement in the study.
Inclusion criteria were students who provided informed
consent and who had completed a course in medical
school for a minimum of one year, excluding those with
chronic medical or psychiatric illness.
Measures
All participants completed the following:
Socio-demographic questionnairecovering information
relating to age, gender, nationality, year of study, etc.
Depression Literacy Questionnaire (D-Lit)
The D-Lit assesses mental health literacy specific to
depression. The instrument was developed in Australia.
Cronbach alpha is 0.70, and its test-retest reliability is r =
0.71.17,18 The questionnaire consists of 22 items.
Respondents can answer each item with one of three
options: True, False, or Don’tKnow.Correct responsesare
given a score of 1. Higher scores indicate greater levels
of depression literacy. D-Lit items are about depression
symptoms, management, treatment, and duration, as well
as differentiation between depression and other mental
illnesses.
Literacy of Suicide Scale (LOSS)
The modified LOSS was used, which retained eight of 12
items measuring knowledge about suicide: signs and
symptoms, causes/nature of suicide, risk factors, and
treatment and preventionn.19,20 The modified LOSS
solicited True, False, Don’t Know responses. Correct
responses are given a score of 1 while incorrect
responses are scored 0. Literacy scores are the sum of all
correctly identified items. Higher scores indicated higher
suicide literacy levels. The scale provides a total literacy
score.
*Scales were applied in English because Arabic was not
the native language for all students.
Analysis
Data were analyzed using the SPSS Statistics 15 (SPSS
15.0). Descriptive statistics were used to express socio-
demographic and clinical characteristics. The distribution
and normality of the sample was assessed with the
Kolmogorov-Smirnov test and found to be significantly
skewed. Since analysis required comparison of two
variables, Mann-Whitney U test was used toexpress the
group difference for clinical variables on the score of
different scales (for comparison of two groups). Chi-
square was used to identify statistically significant
differences between groups. Linear regression was used
to define predictors of literacy.
Results
For the study, 359 students from the clinical and pre-
medical yearsagreed to participate. Age distribution
ranged from 22 to 26 years of age where the mean age
was (20.4±1.7); 320 (89.1 %) were women with 265
(73.8%) living in a college hostel;315 (92.2%) were
Omani. One hundred and five (29.2%) had a history of
previous exposure to psychiatric patients with while 119
(33.1%) had past personnel experience of mental health
difficulties.
Differences on the total score of depression and suicide
literacy between the two groups is shown in Table 1

Elsheshtawy E, Simon M, Golchinheydari S, Al Kharusi J
where the clinical group were significantly statistically
higher (z=8.343. p=.001), (z= 4.563, p=.001),
respectively. As shown in Table 2, there is a significant
statistical difference between the clinical and pre-
medical group of students on most items of the
depression literacy scale whereby the clinical group
scores were higher except on question 5 (behavioral
symptom) (X2=-.048, p=.826), question 3, 6 (psychotic
symptom of depression) (X2=3.596, p= .058 and
X2=3.517, p=.061) and question 19 (management of
depression) (X2=3.368, p=.060). Table 3 indicates a
significant statistical difference between the two groups
on most items of the suicide literacy scale except on
presence of suicidal plan (X2=2.788, p= .095) and the
idea that people with suicidal ideation change their
minds easily (X2=.578, p=.447).
Table 1. Total depression and suicide score in the studied groups
Clinical
Mean ± SD
Pre-medical
Mean ± SD
Z
P
Depressionliteracy (D-Lit)
Total score
12.05 ± 4.2
8.05 ± 3.2
8.343
.001**
Suicide literacy (LOSS)
Total score
4.05 ± 1.8
3.1 ± 1.5
4.563
.001**
Table 2. Depression literacy scale in clinical and pre-medical students
Clinical
No %
Pre-medical
No %
X2
P
Biological symptoms
Q7 (Sleep disturbances) Correct
Incorrect
Q8 (Eating disturbances) Correct
Incorrect
161(85.2)
28(14.8)
167(88.4)
22(11.6)
102(60)
68(40)
116(68.2)
54(31.8)
26.617
22.726
.001**
.001**
Cognitive symptoms
Q2 (guilty feeling) Correct
Incorrect
Q4 (loss of confidence) Correct
Incorrect
Q9 (memory, Concentration) Correct
Incorrect
159(84.1)
30(15.9)
168(88.9)
21(11.1)
126(66.7)
63(33.3)
101(59.8)
68(40.2)
121(71.2)
49(28.8)
91(53.5)
79(46.5)
26.565
17.838
7.016
.001**
.001**
.008*

Mental Health Literacy of Depression and Suicide
Behavioral symptoms
Q5 (behavioral disturbance) Correct
Incorrect
Q11 (motor symptoms) Correct
Incorrect
58(30.7)
131(69.3)
143(75.7)
46(24.3)
52(30.6)
118(69.4)
88(51.8)
82(48.2)
.048
22.215
.826
.001**
Psychotic symptoms
Q1 (irrelevant speech) Correct
Incorrect
Q3 (reckless behavior) Correct
Incorrect
Q6 (hearing voices) Correct
Incorrect
Q10 (multiple personalities) Correct
Incorrect
71(37.6)
118(62.4)
64(33.9)
125 (66.1)
92 (48.4)
97(51.3)
99(52.4)
90(47.6)
26(15.3)
144(84.7)
41(24.1)
129(75.9)
66(38.8)
104(61.2)
46(27.1)
124(72.9)
23.808
3.596
3.517
23.769
.001**
.058
.061
.001**
Impact of depression
Q13 (impaired functioning) Correct
Incorrect
Q14(need for hospitalization) Correct
Incorrect
Q15 (famous people) Correct
Incorrect
96(50.8)
93(49)2
133(70.4)
56(29.6)
137(72.5)
52(27.5)
67(39.4)
103(60.6)
78(45.9)
92(54.1)
102(60)
68(40)
3.7463
23.116
6.828
.053
.001**
.009*

Elsheshtawy E, Simon M, Golchinheydari S, Al Kharusi J
Management of depression
Q12 (role of psychologist) Correct
Incorrect
Q16 (other treatments) Correct
Incorrect
Q17 (role of counselling) Correct
Incorrect
Q18 (role of CBT) Correct
Incorrect
Q19 (role of vitamins) Correct
Incorrect
Q20 (treatment duration) Correct
Incorrect
Q21 (antidepr.addictive) Correct
Incorrect
Q22 (onset of action) Correct
Incorrect
55(29.1)
134(70.9)
44(23.3)
145(76.7)
21(11.1)
168(88.9)
130(68.8)
59(31.2)
75(39.9)
113(60.1)
131(69.3)
58(30.7)
87(46)
102(45)
110(58.2)
79(41.8)
24(14.1)
146(85.9)
17(10)
153(90)
9(5.3)
161(94.7)
66(38.8)
104(61.2)
52(30.6)
118(69.4)
50(29.4)
120(70.6)
30(17.6)
140(82.4)
37(21.8)
133(78.2)
11.673
11.160
3.943
33.564
3.368
58.524
32.731
25.408
.001**
.001**
.047*
.001**
.060
.001**
.001**
.001**
Predictors of higher depression and suicide literacy are shown in Tables 4 and 5.
Predictors of high suicide literacy are shown on Table 4
where for the clinical group, the total depression literacy
score (beta=.356, t=4.410, p=0.001), knowledge about
duration of treatment (beta=.222,t=2.917,p=0.004) and
need for hospitalization (beta=-.165, p=.035). For the
pre-medical group, the predictor was knowledge about
eating disturbance (biological symptom) (beta=.291,
p=0.001).

Mental Health Literacy of Depression and Suicide
Table 3. Suicide literacy scale in clinical and pre-medical students
Clinical G
Premedical G
No %
No %
X2
p
People who have thoughts about suicide should not tell others about it
Correct
140 (74.1)
91 (53.5)
Incorrect
49 (25.9)
79 (46.5)
16.420
.001**
Most people who commit suicide are psychotic
Correct
117 (61.9)
75 (44.1)
Incorrect
75 (44.1)
95 (55.9)
11.455
.001*
People talking about suicide always increase the risk of suicide
Correct
70 (37)
44 (25.9)
Incorrect
119 (63)
126 (74.1)
6.265
.012*
Not all people who attempt suicide plan their attempt in advance
Correct
100 (52.9)
74 (44)
Incorrect
89 (47.1)
96 (56)
2.788
.095
Very few people have thoughts about suicide
Correct
98 (51.3)
45 (26.8)
Incorrect
91 (48.7)
125 (73.2)
4.198
.040*
Men are more likely to die by suicide than women are
Correct
98 (51.3)
45 (26.8)
Incorrect
91 (48.7)
125 (73.2)
21.392
.001*
People who want to attempt suicide can change their mind quickly
Correct
54 (28.6)
50 (29.4)
Incorrect
135 (71.4)
135 (71.4)
.578
.447
There is strong relationship between people’s alcoholism and suicide
Correct
101 (53.4)
61 (35.9)
Incorrect
88 (46.6)
109 (64.1)
10.462
.001**

Elsheshtawy E, Simon M, Golchinheydari S, Al Kharusi J
Table 4. Literacy on predictors of suicide
Clinical group
B
Beta
T
P
Total D-Lit
Q20 (duration of treatment)
Q14 (hospitalization)
.148± .34
.828 ± .284
-.623 ± 293
.356
.222
-.165
4.410
2.917
-2.130
.001
.004
.035
Pre-med group
Q8 (biological symptom)
.948 ± .242
.291
3.924
.001
Dependent factor: total suicide literacy score
Table 5 shows that previous exposure to psychiatric
patients predicted higher scores for both depression and
suicide literacy (for depression literacy; beta=.172,
t=2.307, p=.022, for suicide literacy; beta=.175, t=2.160,
p=.032) while past personal experience predicted better
suicide literacy (beta=.207, t=2.554, p=.011).
Table 5. Effects of past personnel experience or past exposure to mental health difficulties
Dependent factor
Past exposure to
psychiatric patients
Past personal
experience
Dep. Literacy
B
Beta
T
P
1.554 ±.674
.172
2.307
.022
----
Suicide literacy
B
Beta
T
P
0.575 ±.266
.175
2.160
.032
0.683± .267
.207
2.554
.011

Mental Health Literacy of Depression and Suicide
Discussion
To the best of our knowledge, the current study is the
first in Oman to assess depression and suicide literacy
among medical students. The current study explored the
differences in the level of depression and suicide literacy
among medical students: pre-medical (2nd and 3rd year),
clinical students (6th and 7th year); and, to study which
factors might predict better depression and suicide
literacy.
The mean depression literacy score was lower for pre-
medical students than students in their clinical years.
This result was similar to studies from other countries,
such as in Saudi Arabia, Bangladesh, India, and
Vietnam.21,22,23,24 The finding maysuggest that depression
literacy and mental health literacy are poorly understood
in general. It is also possible that lower literacy rates
relating to depression are explained by the absence of
any educational resources focusing on mental health in
the academic curricula taught to students.
Clinical years’ students scored higher on most items of
depression literacy and suicide literacy scales compared
with pre-medical students. The finding is supported in a
study from Sri Lanka and may bea consequence ofhaving
better quality educational programs.25 Of course, in the
clinical phase of training it is more likely that students
will be exposed to educational programs relating to
depression and suicide. A small number of students in
both groups correctly identified the psychotic symptoms
(incoherent speech, unpredictable behavior, and auditory
hallucination), management of depression (role of
psychologist) and behavioral symptoms of depression.
Differences in some aspects of depression literacy in
undergraduate students may result fromvariances in
theirpersonal experiences of and attitudes towards
depression.
Similar results were obtained on the suicide literacy
scale. Students in the clinical group scored significantly
higher on questionnaire items about suicide. A large
percentage of both groups perceived incorrectly that
talking about suicidal thoughts and ideations can increase
the risk of suicide and that suicidal persons can change
their mind easily. This is supported in studies from
Canada and India, which concluded thata person’s
degree of awareness about mental health issues can be
influenced by stigma, social traditions and culture.20,23
Our results may be understood from the perspective of
Oman being a Muslim country where, according to
Islamic Shari'a law, suicide is considered haram - or
forbidden; indeed, families of suicide victims can face
ostracism within the Muslim community.26,27 If a suicide
happens, it is likely to be denied, which may play a role
in delaying and fragmenting any prevention efforts.
Religious restrictions against suicide can affect attitudes
about suicide within the Arab culture and may partially
explain why there is a lower risk of suicidality.
The total score and varied items on the Depression
Literacy Questionnaire predicted higher suicide literacy.
This is supported in studies that concluded both
depression and suicide literacy are inter-related due to an
overlap between symptoms of depression and
suicide.20,23 Previous exposure to psychiatric patients
(family or friends) was found to be a predictor of higher
depression and suicide literacy while past personal
experience predicted high suicide literacy. This could
highlight the importanceof students being exposed to
health information at an early age as having a positive
impact on their levels of literacy, which would also
support our findings.
Conclusions and Recommendations
While possibly expected, there is clear evidence that
depression and suicide literacy among pre-medical
students is lower than it is for students in their clinical
years of medical training. Predictors of higher depression
and suicide literacy include exposure to psychiatric
patients or personal experience of mental health
difficulties as well as the degree to which the students’
respective high school education may have exposed them
to curricula on mental health.
Mental health problems commonly arise during
adolescence; therefore, better integration of mental
health education, particularly in relation to depression
and suicide,would be beneficialduring the high school
years rather than waiting until a medical student reaches
the clinical years of training before such training is
introduced.

The Arab Journal of Psychiatry (

) Vol. 31 No.2 Page (159 – 168) (doi-10.12816/0056867)
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Mental Health Literacy of Depression and Suicide

    

359
 (D- Lit) (LOSS). 
(p = .001 z = 8.343, & z = 4.563, p = .001)
 (p = 0.001)  
 (p = .022 p = .032 .
.
Corresponding Author
Dr Eman Elsheshtawy, Professor of Psychiatry, School of Medicine, Mansoura University, College of Medicine and
Health Science - Sultanate of Oman
Email: emanmady85@yahoo.com
Authors
Dr Eman Elsheshtawy, Professor of Psychiatry, School of Medicine, Mansoura University. College of Medicine and
Health Science - Sultanate of Oman
Dr Miriam Simon, Assistant Professor. Department of Psychiatry and Behavioral Science, College of Medicine and Health
Science, National University of Science and Technology - Sultanate of Oman
Mr Sirous Golchinheydari, Student at College of Medicine and Health Science, National University of Science and
Technology, Sultanate of Oman
Ms Jawaher Al Kharusi, Student at College of Medicine and Health Science, National University of Science and
Technology - Sultanate of Oman