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Quality of Life and Depression in German Medical Students at Foreign Universities

Authors:
Kamiar Rueckert at Johannes Gutenberg-Universität Mainz
Kamiar Rueckert
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Abstract

Aim. With a significantly higher prevalence than the average population, medical students are at risk for depression and a poor quality of life. Studying abroad is an additional source of stress. Medical students studying abroad are facing multifactorial stressors: new culture, new language and a new educational environment. This study aims to find a significant increase in depressive symptoms and a decrease in quality of life in German medical students at foreign universities Methods. A total of 230 students were investigated with the online-based standardized psychologial questionnaires: Q-Les-Q-SF (sensitive measurement of the degree of enjoyment and satisfaction) and PHQ-9 (Depression). Following European countries were investigated: Latvia (L), Hungary (H), Romania (R), Bulgaria (B) and Lithuania (Li). Results. The overall prevalence of clinical relevant depressive symptoms was found to be 23.5%. The prevalence rate of mild depressive symptoms was found to be 40,2%. All in all mild depressive symptoms were found in 40,2% of the students, moderate depressive symptoms were 14.2%, moderate-severe depressive symptoms were 6.6% and severe depressive symptoms made up 2,7%. In Women moderate-severe and severe depressive symptoms were found twice as often. In L the prevalence of clinical significant depression among their students was found to be 15,5%, in H 46,7%, in R 14,8%, in B 0% and in Li 50%. These values are influenced by the small sample size. The small sample size of B and Li may change the results. The Quality of Life decreases with the intensity of the depressive symptoms. The mean Quality of Life was 54,86. Conclusion. With a 2.4 times higher prevalence of depressive symptoms than the German general populations German medical students are at a significantly higher risk of depression. At all foreign universities the quality of life decreased in regard of the severity of the depressive symptoms. With different universities being observed, a different level of depression and quality of life is measured in the students. Due to smaller numbers of students in Rumania, Bulgaria and Lithuania we see a minor limitation in our results. Further investigations of the reasons for depression should be investigated in other studies.
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Quality of Life and Depression in German Medical Students
at Foreign Universities
Author: Kamiar-K. Rueckert
Scientific Research Supervisior: Vladimirs V. Voicehovskis
Riga Stradinš University, Riga, Latvia
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Medical students have a higher exposure to stressors. It includes the
university curriculum, a lack of social interaction outside their profession, as
well as exposure to possible diseases. Long time exposure to stress is known
to increase the prevalence for depression. [1] Studies have shown a
significantly higher prevalence than the average population for medical
students to be at risk for depression. [2]
Migration, whether it is forced or voluntary has an effect on the mental health
and especially depression. [3,4] The short term stay of most
Students may lead to a separation, rather than integrationE! into the native
society. Migration with separation from the native society has shown to have a
higher risk of depression. [5] It is recognized as a multifactorial influence.
Migrants not only have to get acquainted with a new culture and a new
language, but they are also forced to accept this as a normal procedure of
Immigration. Other influences are the loss of affiliation.
We chose the topic “Depression and Quality of Life in German Medical
Students Studying at Foreign Universities” because it combines two factors
increasing the prevalence for depression, as well as being connected with a
significantly lowering of the QoL. Being exposed to a new culture and
language, as well as having to deal with the influences of medical education is
likely to significantly increase the prevalence of depression as well as
decrease the Quality of Life.
No previous study regarding the intercultural well being of German medical
students at foreign universities was conducted, therefore the available
literature is abundant and most references will refer to the level of depression
and QoL in medical students without any regard to migration.
Aim
The aim of this research was to measure the QoL in German medical students
at international universities and to measure the prevalence for depressive
symptoms among the students as well as comparing the results of different
universities.
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Two online-based standardized psychological questionnaires were used to
investigate medical students. The PHQ-9 for the evaluation of depression was
used due to its shortness, simplicity, high sensitivity and specificity and high
reliability, as well as its availability as a non-commercial questionnaire. Based
on 9 questions it defines the level of depression by scoring each question from
0 to 3, providing a 0 to 27 severity score. Ranking 0-4 as none-minimal
depression severity, 5-9 as mild depression severity, 10-14 as moderate
depression severity, 15-19 to moderate severe depressive and 20-27 as
severe depression severity. The questionnaire suggests a treatment starting
from a moderate depression severity [6]. The PHQ-9 was conducted in the
German version due to its availability and to assure that the sample of the
survey were in fact German medical students.
The Q-les-Q-SF is a questionnaire for the sensitive measurement of the
degree of enjoyment and satisfaction by the author J. Endicott [7]. We used a
self-translated version of the Q-les-Q-SF from the original English version into
a German version. This was done because no liable Q-Les-Q-SF version was
found in the German language. The Q-les-Q-SF was chosen to not only
display the QoL in the medical students, but also its correlation to the different
grades of depression being exposed by the medical students. The Quality of
life is a good measurement to display the well being or lack thereof in the
interviewed students. It includes the emotional, social and physical aspects of
the students’ lives that might be affected by the aforementioned multifactorial
stressors. The raw score of the Q-les-Q-SF is converted to a per cent
maximum score with a range of 0-100, where higher scores indicate better
QoL.
The examples of the two questionnaires can be found here at the end of the
research with regard to their language (see attachment No.1 and 2).
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The total number of students interviewed was 230 from the following European
countries: Latvia, Hungary, Rumania, Bulgaria and Lithuania. 4 Invalid replies
occurred, which lowered the total number of students to 226. The distribution
of students is as followed: 129 in L, 60 in H, 27 in R, 8 in B and 2 in Li. The
number of students from different countries differs in respect to the student
population. Unfortunately, no department from H, R, B and Li replied to our
request, therefore the samples relied on the communication with student
organisations and independent student groups. The online survey was
conducted from the 05.05.2015 to 24.06.2015 to ensure that the data was
collected from the middle of the semester. This was designed in order to
capture the average periods of student’s lives and to avoid unusual stress,
such as exam periods. The number of German medical students studying at
foreign universities is not exactly known, but can be assumed to be above
3000, due to L having approximately 700!HIJ, Li 72!H)J. Unfortunately the other
numbers can only be assumed, due to no official information being available.
H has over 4000 international students, of which nearly half are German, and
R and B do not display any information. Our sample size of 226 is small in
comparison to the actual number of German medical students, but the
randomized cross section of the students and the semesters ensures a
representative result.
A control group was not necessary since there are sufficient studies of the
Depression and Quality of life in the general population were found.
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Males
Females
Sample size
109
117
Preclinical semester
67
86
Clinical semester
42
31
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The preclinical semesters are the 1 - 4. Semester. While the clinical semesters
are considered to be the 5 - 12. Semester. Unfortunately the questionnaire is
missing three results in regard of this question. The results show that 2/3 of
the sample was in there preclinical semesters (n=153) and approximately 1/3
was already in the clinical semesters (n=73).
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Males
Females
Latvia
55
74
Hungary
28
32
Bulgaria
5
3
Romania
20
7
Lithuania
1
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The results show a gender well-balanced questionnaire. Since the study was
randomized it can be assumed that the result is close to the normal distribution
of gender with in the medical schools. Deviations in R could be due to the
small sample size.
Table No.3
1. Semester
2. Semester
3. Semester
4. Semester
5. Semester
6. Semester
7. Semester
8. Semester
9. Semester
10. Semester
11. Semester
12. Semester
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If we divide the distribution in perspective of the different semesters, it should
be mentioned that those semesters are not equally presented, and therefore
slight alteration of results can be expected.
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Overall prevalence of mild to severe depression was found to be 59,7%. A
clinically significant prevalence rate of moderate to high severity of depressive
symptoms of 23.5% was found. All in all, mild depressive symptoms were
found in 40,2% of the students, moderate depressive symptoms were 14,2%,
moderate-severe depressive symptoms were 6,6% and severe depressive
symptoms made up 2,7%. In Women, moderate-severe and severe
depressive symptoms were found twice as often.
In L the prevalence of clinical significant depression among their students was
found to be 15,5%, H to be 46,7%, R 14,8%, B 0% and Li 50%. These values
are influenced by the small sample size. The small sample size of B and Li
may change the results.
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The mean QoL measured was 54,86%. The QoL decreases significantly with
the intensity of the depressive symptoms. Non-minimal depressive symptoms
show a QoL of 70.12% with a steady decline to 37.6% for severe depressive
symptoms. Pic. No. 3 illustrates the decrease of QoF in respect of the severity
of depressive symptoms and shows the QoF in none to minimal depression.
Unfortunately no German study was found to compare these results with
German’s general population.
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Pic. No 3
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The following graphic illustrates the level of depression in regard to the gender
of the students. Red being the female students, blue being the male students.
The graphic shows increased moderate and severe depressive symptoms in
females.
Picture No. 4
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The mean QoL of 54,86% was observed in German medical students studying
at foreign universities. A significant decrease in the QoL was observed from
none-minimal depressive symptoms to severe depressive symptoms (Pic. No.
3).
The prevalence of clinically depressive symptoms among the German medical
students is significantly high with 23.5%. Our study concluded a 2.4 times
higher prevalence of depression among German medical students studying at
foreign universities.
In L the prevalence of clinical significant depression among their students was
found to be 15,5%, H to be 46,7%, R 14,8%. The values of R and Li are
influenced by the small sample size. We therefore not mentioned them to
represent the country-specific value, yet are used in the overall analysis.
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Due to our results of the QoL among medical students with a mean of 54.86%
and 70.12% for students with none-minimal depressive symptoms, it can be
concluded that QoL is decreased in medical school in comparison to 83% in
the general population [10]. Yet we see that not only medical school is a
contributor to a low QoL but mainly the prevalence of depression. This raises
the question whether medical schools promote depressive symptoms.
Since other studies suggest a prevalence of depression among medical
students during their medical training between 5%-37.5% [11], we can
conclude that our results of 23,5% fit into the research about depressive
symptoms among medical students. Interestingly our study thereby excludes
the nationality as a significant contributor to the prevalence of depressive
symptoms. Our study (as well as other studies about depressive symptoms in
medical training) shown a significant increase in the prevalence of depression
in comparison to the German general population between the age of 18 - 29
years (9.9%) [12].
These results conclude medical studies promote depressive symptoms. Yet
another question that could be raised is whether medical studies attract
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students prone to depressive symptoms. This thesis could be rejected by a
study published in the Asian journal of psychiatry in 2016, that shows that the
prevalence of depression among entering medical students was low [13].
It seems like all in all, depression, as well as the low QoL are due to the
medical training. It can only be assumed that migration, different-learning
types, as well as other stressors are influencing the prevalence for depression
and QoL. Further studies should be conducted to examine the different
influences leading to depression and a low QoL.
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... This current study is not the first; there are previous studies on depression among university students across the globe [20][21][22][23][24][25][26][27][28][29]. ...
... The study revealed that 1 in 2 students on campus is depressed, ranging from a mood disturbance to extreme depression. This finding is consistent with the reports of previous authors [20][21][22][23][24]. ...
Cross-Sectional Study of Depression and Suicidality Among College Students in University of Port Harcourt, Nigeria
Article
  • Nov 2022
Background: Depression as it were having been defined as a common and serious medical illness that negatively affects how you feel, the way you think and how you. The WHO in a fact sheet report has stated that depression is a common mental disorder and one of the main causes of disability worldwide. They added that globally, an estimated 264 million people are affected by depression. In 2020, an estimated 21.0 million adults in the United States had at least one major depressive episode. The pressure to perform well in school against all odds induces elements of depression when the results are not proportional to the efforts put into the study. Hence, this study was done to assess the level depression and suicidality amongst college students in the University of Port Harcourt, Rivers State, Nigeria. Materials and Methods: The study was descriptive cross-sectional with a total of 104 students who were recruited conveniently from the College of Health Sciences, University of Port Harcourt, Rivers State, Nigeria. The research instrument was a close-ended questionnaire structured in four parts: socio-demography, depression, coping, and suicidality adapted from the Beck-depression-inventory, COPE inventory tool, and Ask Suicide-Screening Questions (ASQ) tool. The statistical analysis was done using statistical package for social sciences (SPSS) version 23. The descriptive statistics was done using simple descriptive tool, chi square test was used to test for association between variables with the confidence interval 95%, p at 0.05 and power of 80. Results and Discussions: Age group (yrs) was the only significant socio-demographic characteristic that was significantly associated (X2 39.102, P=0.001) with depression status. The depression status of the participants showed that those who had Mild mood disturbance were 5(4.8%), Borderline clinical depression 4(3.8%), Moderate depression 10(9.6%), Severe depression 3(2.9%), and Extreme depression 6(5.8%). The study showed ...
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... No consistent value for mental distress among medical students are present [4]. A previous research among the group of tested medical students suggests clinically relevant depressive symptoms among 23.5% [5]. This research aims to determine the prevalence of mental symptoms, somatic symptoms and symptoms of adjustment disorder among medical students in Latvia as well as to display the differences between local and international medical students. ...
... Table 2 displays the students' health-related symptom groups in connection with the psychosocial clusters. The vast majority of international students who reported a stressful life event over the last half-year was in group A or B. The vast majority of Latvian students who reported a stressful life event over the last half-year was in group B or C. Group B: Individuals exceeding one cut-off score University life (5,6) Group C: Individuals exceeding two or more cutoff scores. ...
Cross-sectional study among medical students in Latvia: Differences of mental symptoms and somatic symptoms among Latvian and international students
Research
Full-text available
  • Jun 2018
Introduction. This research aims to determine the prevalence of mental symptoms (depressive symptoms, anxiety and adjustment disorders) and somatic symptoms among medical students at Riga Stradins University in Latvia, as well as to display the differences between local and international medical students. Methods. A cross-sectional study was conducted by means of online-based questionnaires among medical students in their 1 st , 4 th and 6 th years studying in Riga, Latvia, during March 2017. The mental and somatic symptoms were screened with the PHQ-D Option C (PHQ-15, PHQ-9, GAD-7). Symptoms of adjustment disorder were obtained by the ADNM-6. Medical students were divided into three groups according to their answers of the PHQ-D: Group A: no symptom, group B: a single symptom, group C: multiple symptoms. A general questionnaire and a questionnaire regarding stressful life events over the past half-year were distributed additionally. Results. 67 (40.1%) participants were Latvian students; 100 (59.9%) were international students. 23 (34.3%) Latvian students were in group A, 20 (29.9%) in group B, 24 (35.8%) in group C. 51 (51%) international students were in group A, 34 (34%) in group B, 14 (14%) in group C. Latvians displayed statisti cally significantly more health-related symptoms (0.003). 11 (11%) international students who reported a stressful life event over the last half-year were in group C. 21 (31.3%) of Latvian students who reported a stressful life event over the last half-year were in group C. 73 (43.7%) of all students had experienced stressful life events and displayed troubles adjusting to them. 65 (63.1%) students of the two groups with a stressful life found the event to have a great burden on them, 63 (61.2%) were wondering whether it could happen again, and 73 (70.9%) tried to suppress their feelings. Conclusion. Medical students in Latvia have a high prevalence of health-related symptoms. Latvian medical students display more health-related
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... Depression possibly came with underlying burnout, leading to more severe depression [23,39,40]. Previously reported depression rates in medical students seemed to be depending on the sample, measured at as high as 51.3% in one medical school in India, while it was 23.5% among German medical students [41,42]. According to a study, the medical student anxiety level was at the 85 th percentile compared to the age-matched peers in the general population [14,43]. ...
Final-year medical student mental wellness during preparation for the examination for specialty in Turkey: a cross-sectional survey study
Article
Full-text available
  • Feb 2023
  • BMC Med Educ
Background In Turkey, most final-year medical students prepare for the Examination for Specialty in Medicine in a high-stress environment. To the best of our knowledge, this is the first study on final-year medical student general psychological distress during preparation for the Examination for Specialty in Turkey. We aim to evaluate psychological distress and understand the variables associated with depression, anxiety, and stress levels among final-year medical students preparing for the Examination for Specialty. Methods A self-reporting, anonymous, cross-sectional survey with 21 items consisting of demographic variables, custom variables directed for this study, and the DASS-21 was utilized. Survey results were expounded based on univariate analysis and multivariate linear regression analysis. Results Our study revealed four variables associated with impaired mental wellness among final-year medical students during preparation for the examination for Specialty: attendance to preparatory courses, duration of preparation, consideration of quitting studying, and psychiatric drug usage/ongoing psychotherapy. Discussion Considering that physician mental wellness is one of the most crucial determinants of healthcare quality, impaired mental wellness among future physicians is an obstacle to a well-functioning healthcare system. Our study targets researchers and authorities, who should focus on medical student mental wellness, and medical students themselves.
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... My first research as a student focused on the mental symptoms of international students and later the emotional adaptations to stressful life events (Rueckert and Ancane, 2018;Rueckert, 2016). Both hold their biases. ...
Addressing medical students with psychodynamic education
Article
Full-text available
  • Jun 2019
Mental symptoms rank high among medical students and residents. Roughly one fourth of the student body is affected. This widespread presence may influence the core of our profession: Emotions. Medical students who tend to suppress their negative emotions display a higher prevalence of depressive symptoms, anxiety and distress. The patients’ symptom onset is often linked to a specific time of personal significance. Patients regularly offer a relationship by pointing towards psychosocial issues. The students’ suppression of negative emotions may lead to a neglect of topics connected to these emotions during history taking. This leads to an abandonment of the biopsychosocial model of health and inhibits the growth of a doctor-patient relationship. We need preventive measures to decrease the high prevalence of mental symptoms and improve our patient’s health. Mandatory classes on patients’ psychosocial clues and students’ emotional response could improve two crucial points: The reduction of the students’ own symptoms and a curious investigation of the patient’s entire history. This personal view by a German MD is a pledge for a paradigm shift in the medical curriculum.
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... at fifth year [4]. Studies have shown prevalence rates as high as 51.3% amongst medical students in one of the institution in India while that of German medical students studying in different institutions across Europe showed a prevalence rate of 23.5% [5,6]. One such study conducted in one of the premiere institution of the USA showed a prevalence rate of moderate to severe depression as 14.3% [7]. ...
Dear depression, why do you even exist in the budding medicos?
Article
Full-text available
  • Mar 2017
It is a matter of fact that the high demands and pressure of medical school and pre-residency entrance tests pose a tremendous challenge to the personal wellbeing for the physicians in training which leads to high rates of anxiety, burnout, decreased attention, increased incidence of errors, negligence and depression.
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[Prevalence of depressive symptoms and diagnosed depression among adults in Germany : Results of the German Health Interview and Examination Survey for Adults (DEGS1).]
Article
Full-text available
  • May 2013
  • BUNDESGESUNDHEITSBLA
In the German Health Interview and Examination Survey (DEGS1), current depressive symptoms were assessed with the "Patient Health Questionnaire" (PHQ-9) in a representative population-based sample of 7,988 adults 18-79 years old. In addition, previously diagnosed depression was assessed by physician interview. The prevalence of current depressive symptoms (PHQ-9 ≥ 10 points) is 8.1 % (women: 10.2 %; men: 6.1 %). For both sexes, the prevalence is highest among 18- to 29-year-olds and decreases with age. Persons with higher socioeconomic status (SES) are less likely to have current depressive symptoms. The lifetime prevalence of diagnosed depression is 11.6 % (women: 15.4 %; men: 7.8 %) and is highest among persons 60-69 years old. The 12 month prevalence is 6.0 % (women: 8.1 %; men: 3.8 %) and is highest among 50- to 59-year-olds. In women, but not in men, prevalences decrease with increasing SES. The results describe the distribution of two important aspects of depression among the adult population in Germany and confirm previously observed associations with age, gender and SES. An English full-text version of this article is available at SpringerLink as supplemental.
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Depressive symptoms among immigrants and ethnic minorities: A population based study in 23 European countries
Article
Full-text available
  • Nov 2010
  • SOC PSYCH PSYCH EPID
European studies about ethnic inequalities in depressive symptoms are scarce, show inconclusive results and are complicated by the discussion of what constitute (im)migrant and ethnic minority groups. Moreover, comparisons across countries are hampered by a lack of comparable measures of depressive symptoms. This study aims to assess the prevalence and determinants of depressive symptoms among immigrants, ethnic minorities and natives in 23 European countries. Multilevel analyses are performed using data from the third wave of the European Social Survey (ESS-3). This dataset comprises information about 36,970 respondents, aged 21 years or older, of whom 13.3% immigrants and 6.2% ethnic minorities. Depressive symptoms were assessed with an 8-item version of the Center for Epidemiologic Studies-Depression scale. Main determinants are immigrant status, socio-economic conditions and the experience of ethnic discrimination in the host country. The results show that immigrants and ethnic minorities do experience more depressive symptoms than natives in an essential part of the countries. Moreover, socio-economic conditions and the experience of ethnic discrimination are important risk factors. Immigrant status seems irrelevant, once the other risk factors are accounted for. Finally, immigrant and ethnic minority groups do not consist of the same individuals and therefore have different prevalence rates of depressive symptoms. The prevalence rates of depressive symptoms are higher for immigrant and ethnic minority groups in a substantial part of the European countries. A clear definition is indispensable for developing policies that address the right-targeted population.
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The PHQ-9: A New Depression Diagnostic and Severity Measure
Article
  • Sep 2002
The nine-item Patient Health Questionnaire depression scale is a dual-purpose instrument that can establish provisional depressive disorder diagnoses as well as grade depression severity.
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Effect of medical school stress on the mental health of medical students in early and late clinical curriculum
Article
  • Nov 1991
Earlier research has shown that medical students in the United Kingdom and the United States report a higher level of nervous symptoms than the general population. To better understand how medical students in Norway compare with these findings, 299 male and female students in the clinical curriculum at the University of Oslo were asked to complete a questionnaire about themselves and their mental health. Medical students in Norway do not differ from the general population in mental health. However, the students report a lower level of general self-esteem than the general population. The male students had more nervous symptoms and a less general self-esteem than the female students compared with the general population. This research also shows that medical school stress is a good predictor of nervous symptoms even when psychosocial variables such as marital or cohabitation status, confident other and general self-esteem are taken into consideration.
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Endicott J, Nee J, Harrison W, Blumenthal R. Quality of Life Enjoyment and Satisfaction Questionnaire: a new measure. Psychopharmacol Bull 29: 321-326
Article
  • Feb 1993
  • Psychopharmacol Bull
The Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) is a self-report measure designed to enable investigators to easily obtain sensitive measures of the degree of enjoyment and satisfaction experienced by subjects in various areas of daily functioning. The summary scores were found to be reliable and valid measures of these dimensions in a group of depressed outpatients. The Q-LES-Q measures were related to, but not redundant with, measures of overall severity of illness or severity of depression within this sample. These findings suggest that the Q-LES-Q measures may be sensitive to important differences among depressed patients that are not detected by the measures usually employed.
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Generic and health related quality of life in patients with seasonal and nonseasonal depression
Article
  • Nov 2004
  • PSYCHIAT RES
Although a relatively large body of research has now accumulated concerning the relationship between quality of life (QoL) and nonseasonal depression, there is a dearth of information about QoL in seasonal affective disorder (SAD). The aim of this study was to compare perceived levels of broad ('generic') and health-related QoL in patients with seasonal and nonseasonal depression. Participants were 72 patients with SAD enrolled in an on-going multicentre study in Canada, and 72 patients with nonseasonal major depressive disorder (MDD) matched for severity of depression attending an outpatient psychiatric clinic in Vancouver, British Columbia. All participants completed two measures of QoL (the 20-item Medical Outcomes Study [MOS] Short-Form General Health Survey [SF-20] and the Quality of Life Enjoyment and Satisfaction Questionnaire [Q-LES-Q]) at baseline prior to treatment. The results of the study indicated that both generic and health-related QoL were compromised in patients with SAD compared with general population norms. For example, mean Q-LES-Q scores (range 0-100, where higher scores indicate better QoL) were 44%, compared with scores of 83% reported for the general population. Patients with nonseasonal depression showed significantly poorer functioning in several domains on the SF-20, but no significant differences in Q-LES-Q scores emerged. Perceived QoL is impaired in patients with SAD. Degree of impairment between seasonal and nonseasonal depressives is equivalent when assessed using the Q-LES-Q, but significant inter-group differences are apparent in SF-20 domain scores. Future research is required to determine whether perceived QoL is improved by treatment interventions for seasonal depression such as light therapy or antidepressant medication.
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Sind Migranten häufiger von psychen Stärugnen betroffen?
  • Jan 2009
  • 16-22
  • H Glaesmer
  • U Witting
  • E Brähler
Glaesmer H, Witting U, Brähler E et al. Sind Migranten häufiger von psychen Stärugnen betroffen? Psychiatr Prax 2009, 36:16--22
Depressive and anxiety disorders in different ethnic groups: a population based study among native Durch and Turkish, Moroccan and Surinamese migrants in Amsterdam
  • Jan 2008
  • 905-912
  • Wit De
  • Mas
  • W C Tuinebreijer
  • J Dekker
de Wit Mas, Tuinebreijer WC, Dekker J et al. Depressive and anxiety disorders in different ethnic groups: a population based study among native Durch and Turkish, Moroccan and Surinamese migrants in Amsterdam. Soc Psychiatry Psychiatr Epidemiol 2008;43:905--912
Quality of Life Enjoyment and Satisfaction Questionnaire: A New Measure
  • Jan 1993
  • 321-326
  • J Endicott
  • J Nee
  • W Harrison
  • R Blumenthal
Endicott J, Nee J, Harrison W, Blumenthal R. Quality of Life Enjoyment and Satisfaction Questionnaire: A New Measure. Psychopharmacology Bulletin 1993;29:321-­‐326.
Generic and health-­-related quality of life in patients with seasonal and nonseasonal depression
  • Jan 2005
  • E E Michalak
  • E M Tam
  • C V Manjunath
  • Levitt
  • J Anthony
  • R D Levitan
  • R Lam
Michalak E E, Tam E M, Manjunath CV, Levitt, Anthony J, LEvitan R D, Lam R w. Generic and health-­-related quality of life in patients with seasonal and nonseasonal depression. Can J Psychiatry 2005, 50,