ArticleLiterature Review

Female undergraduate dental students may present higher depressive symptoms: A systematic review

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Abstract

Depressive disorder is a prevalent mental disorder that may be manifested by dysphoric mood and loss of interest or pleasure in daily activities (de Zwart, Jeronimus, & de Jonge, 2018). Episodes of depression may be triggered by mild chronic stress (Mahar, Bambico, Mechawar, & Nobrega, 2014). Higher workload, emotional burden, and demand for technical skills may be examples of stressors that are increased in dental students (Alzahem, Van der Molen, & De Boer, 2013). Therefore, it is not surprising that dental students may experience elevated rates of depression when compared with the general population. This article is protected by copyright. All rights reserved.

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... Students are a population particularly susceptible to mental health issues. Several studies have confirmed that students of medicine, nursing, pharmacy, midwifery, dentistry and physiotherapy exhibit an increased incidence of the symptoms of depression [49][50][51][52] and anxiety [53][54][55][56] compared to students of non-medical majors. ...
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(1) This study analysed the relationship between positive orientation and subjective control of anger, anxiety and depression in nursing students in Poland, Spain and Slovakia during the pandemic. (2) The survey was carried out by the diagnostic survey method in a group of 756 nursing students in Poland, Spain and Slovakia. The empirical data were gathered using an original survey questionnaire, the Positive Orientation Scale and the Courtauld Emotional Control Scale. (3) It was shown that the positive orientation level in Polish students was significantly lower than in students in Spain (p < 0.0001) and Slovakia (p < 0.0001). Low results for positive orientation were obtained in nearly half (47.18%) of the respondents in the Polish sample, whereas it was 34.18% and 31.18% in the Spanish and Slovak samples, respectively (p < 0.0001). A positive orientation was the most important predictor of emotional control among the nursing students at all the sites (p < 0.0001). (4) Positive orientation has been shown to have a significant impact on emotional control in nursing students during the pandemic. Therefore, it is important to carefully monitor students’ mental health during the pandemic to determine the demand for psychological and emotional support.
... 14e16 Similarly, recent systemic reviews of medical and dental students indicate the association of gender with depressive symptoms. 17,18 It is documented that psychological distress such as anxiety, depression, and conflicting demands are more common among females than males, which may reduce their resistance to diseases. 19 There is evidence that female students complain more about the study material they have to cover, report stress more frequently than male students, and over-report symptoms of medical and psychological conditions. ...
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Objective The study was conducted to assess test anxiety and its influencing factors on medical and dental students. Methods A cross-sectional study was conducted among students from three private and public medical and dental colleges in the Punjab province of Pakistan. The survey included statements about the demographic profile of the study participants and used the Test Anxiety Inventory (TAI) by Spielberger. Results The study included 680 students with a mean age of 20.93 ± 1.76 years. About half the sample (51.8%) scored high on test anxiety (TAI score > 45), and the mean TAI score was slightly higher for the dental (47.75 ± 11.45) than medical students (46.42 ± 12.79). Female students had a significantly higher mean TAI score (48.45 ± 12.79) than male students (41.85 ± 8.91; p < 0.001). The students from private colleges had a significantly greater test anxiety score (50.15 ± 13.23) than students from public colleges (42.88 ± 9.7; p < 0.001). Students whose parents were graduates from a college or university perceived significantly increased test anxiety than those of parents with no education (p < 0.001). A female gender (adjusted odds ratio (AOR) 2.10, 95% CI:1.37, 3.22), being a private college student (AOR 2.88, 95% CI:1.90, 4.38), and having a mother with a college or university education (AOR 2.05, 95% CI: 1.25, 3.35) were significantly associated with high test anxiety. Conclusion In our study cohort, test anxiety was common among medical and dental students. A female gender, being a student from a private college, and having a mother with a high education were significantly associated with high test anxiety. The study findings may guide the development of programs that can reduce students’ test anxiety and potentially improve their education.
... 17 Additionally, the most significant predictors of suicidal behavior are aspects related to hopelessness, depression, stress, and coping styles, which makes it important to identify these characteristics early. 18 The literature states that female undergraduate dental students (general dentistry) may present higher depressive symptoms, 19 but not synthetized data are available for students of different years of education. It is important to consider that different years of education may represent different experiences for undergraduate students. ...
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Objective: This study aimed to systematically review the literature about the prevalence of self-reported depressive symptoms in dental students. Methods: PUBMED, SCOPUS, and EMBASE databases were search up to January 2020 with the following focused questions: "What is the prevalence of self-reported depression symptom in dental students?" and "Are sex and years of educational training associated with self-reported depressive symptom in dental students?". Observational studies that applied a questionnaire assessing depression were eligible. Standard mean differences (SMD) and pooled odds ratios (OR) were calculated for the questionnaires' scores and self-reported depressive symptom, respectively. Results: Fifty-eight studies were included, and 15 different questionnaires were used. The prevalence of self-reported depressive symptoms/at least mild depression ranged from 2.75% to 89.84%, and the pooled overall prevalence was 29% (95% confidence interval [CI]: 26-34). Meta-analysis showed significantly lower scores in the questionnaires for self-reported depressive symptoms of male students (SMD: -0.22; 95% CI: -0.42 - -0.03). Conversely, no significant difference was detected for the OR of self-reported depressive symptom in the comparison between sex (OR: 1.11 - 95% CI: 0.77-1.62). Similarly, no significant difference was observed for the different school years regardless of the analytical strategy used. Conclusion: It was concluded that female dental students presented more self-reported depressive symptoms, but no difference is demonstrated during the years of dental education.
... Depression is a major challenge for undergraduate university students. [1][2][3][4][5] Studies have shown that 25% of students worldwide meet the threshold for major depression at any given time. 3 The prevalence of depression has been estimated to range from 1.6% (severe depression) to 58.2% (mild depression) in student populations in Nigeria, 4,5 and depression is common among chemistry education undergraduates in Nigerian universities. ...
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Objective We assessed the efficacy of a rational-emotive behaviour therapy psycho-educational programme in reducing depression among chemistry education undergraduates in a Nigerian university. Methods Twenty-three chemistry education undergraduates with major depressive disorder were randomised to a treatment group (12) or control group (11). Students were scored using Beck’s Depression Inventory three times (pre-test, post-treatment, and follow-up). An evidence-based protocol for combating depression was used in the treatment. Controls received counselling. Data were evaluated using univariate analysis of variance and two-way mixed analysis of variance. Results Mean depression scores did not differ between groups prior to the intervention. Rational-emotive behaviour therapy was effective in reducing depression scores. Conclusion Rational-emotive behaviour therapy is an effective tool in assisting university undergraduates (of chemistry education) to manage depression.
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Introduction: Health sciences students usually report high rates of mental health problems. The COVID-19 pandemic context may have serious psychological impacts in this at-risk population. We aimed to assess the self-reported mental health status, health-related quality of life and coping strategies of health sciences students during the early stage of the pandemic. Method: An online 128-item questionnaire sent to 17,673 health sciences students from the Claude Bernard University Lyon 1 in April 2020 assessed: a) sociodemographic characteristics, b) conditions of lockdown, c) depressive (Beck Depression Inventory- Short Form, BDI-SF), anxiety (State-Trait Anxiety Inventory-A, STAI-A) and traumatic symptoms (Impact of Event Scale -Revised, IES-R), d) health-related quality of life (SF12) and e) coping strategies (Brief Coping Orientation to Problems Experienced, Brief COPE). Results: The participation rate was 9.9% (n= 1,765). A total of 19.5% of participants reported an IES-R>33, 11.6% depressive symptoms, 58.1% anxiety symptoms, and 4.4% suicidal ideation. Their mental health-related quality of life was significantly poorer than for physical health. Female gender, COVID-like symptoms, social isolation due to the lockdown, pandemic-related financial restraint and exams-related stress were significantly associated with poorer self-reported mental health conditions. Volunteering in the healthcare system was significantly associated with lower mental health scores. Coping strategies were mostly oriented toward avoidance and positive appraisal. Conclusion: French health sciences students exhibited high levels of self-reported mental health problems and a poor mental health-related quality of life during the early stage of the COVID-19 pandemic. Specific risk factors related to the pandemic partly explain the observed prevalence.
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Introduction: This study aimed at determining the frequency and association of stress levels with modes of transportation and was likely to reveal the contributing transportation-related factors for stress in medical students. Methods: This was a questionnaire-based, cross-sectional study that included undergraduate medical students of a public sector medical university in Karachi, Pakistan. A total of 573 students participated voluntarily, of which 300 were provided a manual questionnaire and 273 filled it online. The reliability of the questionnaire was assessed using Cronbach's alpha at 0.791. The collected data were analysed using IBM SPSS Statistics for Windows, version 21.0. Results: Out of 573 participants, 99.3% (n = 298) of students filled the questionnaire manually, whereas 100% of students filled the questionnaire online. Almost two-thirds of students used university transport; more than 90% lived more than 5 km from the university and 56% had a traveling time of more than an hour. Approximately 15.4% of students reported physical trauma and some form of harassment. Sheldon Cohen's stress scale surprisingly revealed 90% of students to be within the moderate-to-high stress category. Risk factors were associated with stress levels and significant associations were observed with noise exposure (P = 0.023) and sleep quality (P = 0.001). The most common reported stressors associated with commuting included overcrowding, long travel, and air and noise pollution. Noise pollution was the main predictor of stress among commuters. Conclusion: Poor transportation has adverse effects on health and academic performance. Administration in their respective jurisdictions is needed to investigate this matter to make commuting a routine rather than a hassle.
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Aims.: For the past quarter of a century, Frank et al.'s (1991) consensus-based definitions of major depressive disorder (MDD) episode, remission, recovery, relapse and recurrence have been the paramount driving forces for consistency in MDD research as well as in clinical practice. This study aims to review the evidence for the empirical validation of Frank et al.'s proposed concept definitions and to discuss evidence-based modifications. Methods.: A literature search of Web of Science and PubMed from 1/1/1991 to 08/30/2017 identified all publications which referenced Frank et al.'s request for definition validation. Publications with data relevant for validation were included and checked for referencing other studies providing such data. Results.: A total of 56 studies involving 39 315 subjects were included, mainly presenting data to validate the severity and duration thresholds for defining remission and recovery. Most studies indicated that the severity threshold for defining remission should decrease. Additionally, specific duration thresholds to separate remission from recovery did not add any predictive value to the notion that increased remission duration alleviates the risk of reoccurrence of depressive symptoms. Only limited data were available to validate the severity and duration criteria for defining a depressive episode. Conclusions.: Remission can best be defined as a less symptomatic state than previously assumed (Hamilton Rating Scale for Depression, 17-item version (HAMD-17) ⩽4 instead of ⩽7), without applying a duration criterion. Duration thresholds to separate remission from recovery are not meaningful. The minimal duration of depressive symptoms to define a depressive episode should be longer than 2 weeks, although further studies are required to recommend an exact duration threshold. These results are relevant for researchers and clinicians aiming to use evidence-based depression outcomes.
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Objectives To measure the occurrence and levels of depression, anxiety and stress in undergraduate dental students using the Depression, Anxiety and Stress Scale (DASS-21). Methods This cross-sectional study was conducted in November and December of 2014. A total of 289 dental students were invited to participate, and 277 responded, resulting in a response rate of 96%. The final sample included 247 participants. Eligible participants were surveyed via a self-reported questionnaire that included the validated DASS-21 scale as the assessment tool and questions about demographic characteristics and methods for managing stress. Results Abnormal levels of depression, anxiety and stress were identified in 55.9%, 66.8% and 54.7% of the study participants, respectively. A multiple linear regression analysis revealed multiple predictors: gender (for anxiety b=-3.589, p=.016 and stress b=-4.099, p=.008), satisfaction with faculty relationships (for depression b=-2.318, p=.007; anxiety b=-2.213, p=.004; and stress b=-2.854, p<.001), satisfaction with peer relationships (for depression b=-3.527, p<.001; anxiety b=-2.213, p=.004; and stress b=-2.854, p<.001), and dentistry as the first choice for field of study (for stress b=-2.648, p=.045). The standardized coefficients demonstrated the relationship and strength of the predictors for each subscale. To cope with stress, students engaged in various activities such as reading, watching television and seeking emotional support from others. Conclusions The high occurrence of depression, anxiety and stress among dental students highlights the importance of providing support programs and implementing preventive measures to help students, particularly those who are most susceptible to higher levels of these psychological conditions.
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Background There is a need to better understand the depression phenomenon and to clarify why some students become depressed and others don’t. The purpose of this study was to compare the prevalence of depressive symptoms among health professions’ (HP) students, and to explore the association between socio-demographic factors (e.g. year of study, discipline, gender) and depressive symptoms. Methods In this descriptive–analytic, cross-sectional study, stratified proportionate sampling strategy was used to select the study sample during the academic year 2012–2013. The students from four health professions’ schools situated within a large, public university located in Riyadh, Saudi Arabia were screened for depressive symptoms using the 21-item Beck Depression Inventory (BDI II). Chi-square test, student t-test and ANOVA were used to compare different categorical variables. ResultsThe overall response rate was 79.0 %, the highest among dental students 86.1 %, and lowest among nursing (49.7 %). The overall prevalence rate of depressive symptoms was 47.0 %; it was highest among dentistry students (51.6 %), followed by medicine (46.2 %), applied medical sciences (AMS) (45.7 %) and lowest among nursing students (44.2 %). A statistically significant association was found between the presence and severity of depressive symptoms on one hand and the female gender (p = 0.000) and year of study on the other hand. Conclusion This study seems to indicate an alarming rate of depressive symptoms. Female gender, dentistry, the third year for all schools and fifth year for medicine and dentistry have the highest association with depressive symptoms. Future studies may be needed to explore further the reasons and explanations for the variation in the prevalence of depressive symptoms among these groups. The factors that deserve exploration include curricular variables and personal factors such as the students’ study skills.
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Objectives To estimate the relationship between depressive symptoms, anxiety and stress and socio-demographic, academic and social factors among dental students. Methods A cross-sectional study was carried out on dental students from a university in Cartagena, selected by simple random sampling. Students answered a self-report anonymous questionnaire of 20 questions that included demographic characteristics, depression, anxiety and stress symptoms (DASS scale 21), family function (APGAR family) and other factors associated with the academic, economic and social context. Data were analyzed computing odds ratios by binomial logistic regression. Results The prevalence of symptoms of anxiety, depression and stress were 37.4%, 56.6% and 45.4%, respectively. Factors associated with depressive symptoms were lack of support from friends (OR=6.2; 95%CI, 2.6–14.5), family dysfunction (OR=3.6; 95%CI, 1.9–6.6) and economic hardship (OR=2.2; 95%CI, 1.2–3.9). The anxiety symptoms were associated with family dysfunction (OR=3.1; 95%CI, 1.8–5.3) and lack of support from friends (OR=2.1; 95%CI, 1.1–5.8). Also for symptoms of stress factors family dysfunction (OR=2.3; 95%CI, 1.4–4.1), income (OR=2.4; 95%CI, 1.2–4.9) and time to rest (OR=2.3; 95%CI, 1.4–4.0). Conclusions Dental students report a high prevalence of symptoms of anxiety, depression and stress. Associated factors are economic resources, family function, lack of time for rest, and social support.
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Stress among dental students can be a significant threat, resulting in physical and/or mental illness, and have a negative effect on students' performance and the professional practice of dentistry. Stress can occur from different sources. The purpose of this study is to test whether the year of study has an effect on the stress levels of dental students. Our study consisted of a cross-sectional survey using a modified version of the Dental Environment Stress (DES) questionnaire. The questionnaires were filled out by male undergraduate dental students at King Saud University in Riyadh City during the 2010-2011 academic year (n = 214). THE RESULTS SHOW THE MOST COMMON SOURCES OF STRESS: examinations and completing clinical requirements. Moreover, in the five-year lecture-based traditional curriculum, the third year students reported the highest level of stress, whereas the first year reported the lowest level of stress. Third year undergraduate dental students reported the highest level of stress. This stress could be reduced by reviewing and modifying the dental curriculum by allowing students to have contact with patients more gradually, starting from the first year, in addition to adding stress prevention and intervention programs in dental curricula.
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To investigate alcohol and illicit drug use in a cohort of dental undergraduates through to VT year. A UK dental school (with a medical school comparison group). A cohort of dental students anonymously completed a lifestyle questionnaire about drinking and smoking, illicit drug use, stress, anxiety and depression in the spring of 1995 and 1998 as second and final year undergraduate students respectively, and in the summer of 1999 after one year working as qualified dentists. A parallel cohort of medical students also anonymously completed the questionnaire at the same time points in their undergraduate course as for the dental students, and at the end of a year working as Pre-Registration House Officers (PRHOs). The proportion of dental students in Newcastle drinking above the recommended low risk limits of alcohol declined from 47% as second year students to 25% as final year students and then it increased to 41% as qualified dentists, whilst in medical students it steadily increased over the three time points of the survey (33% to 43% to 54%). A greater proportion of dental students were drinking at hazardous levels at all three time-points, compared with medical students. Experimentation with illicit drugs ranged from 47% as second year students to 54% as final year students and to 51% as dentists. The prevalence of illicit drug use in medical students was similar to that in dental students. Forty seven per cent of the dental student cohort as second year students, 67% as final year students and 16% as dentists suffered from possible pathological anxiety, compared with 47%, 26% and 30% in the medical student cohort. The proportion of dentists suffering from stress decreased from 72% as final year students to 19% as dentists. In the medical student group, the proportion increased from 32% as final year students to 39% as PRHOs. This longitudinal study revealed that a high proportion of dental students from Newcastle continue to drink excessively and experiment with illicit drugs both as undergraduates and as practising dentists. A significant proportion also suffer from anxiety and stress. Further measures are needed in order to reduce alcohol and substance misuse and stress and anxiety among dental students and dentists.
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Background: Medical is a sensitive profession, needs dedication, hard work as well as good physical and mental health. The Initial years of undergraduate (medicine and dentistry) are tough, but comparatively work load on the student of dentistry is higher in the initial years. They study almost all subjects of basic sciences along with dental subjects in a limited period of time, which may increase the burden and leads to depression, anxiety and stress among students especially before final exam. Aim: To assess the stress, anxiety and depression level in dental students especially before exams. Study design: Descriptive Cross sectional study Place and duration of study: This study was conducted at University college of medicine and dentistry from September to November 2016. Method: A pre structured, valid and reliable questionnaire DASS 21 was used to access the depression, anxiety and stress in the students of the first and second year BDS. 77 students from first year and 75 students from second year BDS were enrolled. A Questionnaire was distributed among the BDS students three weeks before the final examination in university of Lahore. Results: Out of 152 students 129 students completed the questionnaire. The response rate was 84.9%. The prevalence of depression, anxiety and stress was 31%, 41.9% and 12.5% respectively. First and second shows significant difference in depression and stress scores, both have the p-value < 0.05. Female students show depression (20%), anxiety (22.4%) and stress (6.6%), while male student's has depression (10%), anxiety (14%) and stress (5.3%). Conclusion: The results showed that first year dental, medical students constitute a vulnerable group that has a high prevalence of psychiatric morbidity comprising of depression, stress and anxiety as compare to the second years dental students, similarly female are more prone to depression, stress and anxiety than males.
Article
Background: Depression is a common disorder that impacts an individual's ability to perform life activities, including those required by the workplace. Academic performance can be viewed as a direct parallel to workforce performance, with students belonging to a unique set of individuals whose ability to perform can be measured on criteria applied by an observer and by self-report. While the prevalence of depression for this group is high and preparation for entry into the workplace is critical for these individuals, this relationship has not been adequately investigated. Aims of the study: This study investigates the relationship between depression and its treatments and the academic performance of undergraduate students. Methods: Data regarding academics, health and productivity for students from Western Michigan University were obtained from the University's Registrar's Office, the campus Health Center and a survey delivered to the students. The primary outcomes of interest were the student's grade point average (GPA), an objective, observer generated measure of academic productivity, and the students' self-reported academic performance. Results: Diagnosed depression was associated with a 0.49 point, or half a letter grade, decrease in student GPA, while treatment was associated with a protective effect of approximately 0.44 points. The self-reported data regarding the impact of depression on the performance of academic tasks was consistent with these findings. Depressed students reported a pattern of increasing interference of depression symptoms with academic performance peaking in the month of diagnosis and decreasing thereafter with the lowest levels reported in months 4 through 6 post-diagnosis, each of which is significantly less than the month of diagnosis. Discussion: The finding of a significant relationship between depression and academic performance was robust to the variety of analyses employed within this study. However, interpretation of the findings must be tempered by a number of facts. The sample was drawn from a subset of students at a single university, those willing to complete a questionnaire regarding their health and productivity. Due to non-availability of the treatment data from other health care providers, the treatment variable used within the regression models represents an imprecise proxy for the totality of treatment methods received by depressed subjects from a variety of on-campus and off-campus health care providers. Another challenge to the interpretation of this data is the interrelatedness of depression and school performance. Because of this, it was not possible to evaluate the extent to which the association between depression and academic performance is driven by causality in either direction. Implications for health care provision and use: While depression and its effects have been studied in many different population groups and subgroups, the effect of this disease on college students has not been well documented. This research demonstrates the impact of depression and the effectiveness of its treatment on a student sample. From a public health perspective, this analysis highlights the importance of access to mental health treatment facilities among the college aged and the potential value of efforts to educate this population segment on the availability of that resource.
Article
The Zung Self-Rating Depression Scale (SDS) is generally used to screen for the presence of depression. The purpose of this study was to investigate scores on the SDS, Japanese version, in undergraduates at Tsurumi University School of Dental Medicine in Yokohama, Japan. A total of 2,197 dental students completed the SDS from 2006 through 2008. The investigation took place each year over a 3-week period from June to July. When investigating, the Institutional Review Board at Tsurumi University approved the study. Students could voluntarily agree or decline to participate in the study, and all responses were provided anonymously. SDS scores by sex, class year, and change over time were analyzed. The mean SDS score ranged from 43.7 ± 8.5 to 44.8 ± 9.0 between 2006 and 2008. Women were significantly more depressed than men in 2007 and 2008. The SDS scores of the same students were high continuously for 2 years. "Diurnal variation," "personal devaluation," and "confusion" had the highest scores of the 20 individual items of the SDS. Of the participating students, 31.4-37.2% were classified as being moderately to severely depressed. Logistic regression analysis was used to compute the odds ratio for SDS scores of ≤47 versus ≥48. The item "suicidal rumination" had the highest chance of being associated with depressive symptoms in all 3 years. Although this research was limited to a single department of dentistry, it appears that dental students experience various levels of depression. Providing mental healthcare options to these students may be helpful.
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The authors measured the prevalence of depressive symptoms among dental students at a historically black college in the United States to determine how depressive symptoms, stress, and social support influence each other within this student population. Dental students (n = 143) completed a self-administered survey to assess depressive symptoms, stress, and social support, using validated and reliable instruments. Participants also reported demographic variables. The authors used multivariable linear regression controlling for potential confounding. The prevalence of depressive symptoms was 16.7%. There were significantly higher levels of stress for students with depressive symptoms compared with those without such symptoms (p < .01), and students with depressive symptoms had significantly lower levels of social support (p < .01). Results show higher levels of depressive symptomatology to be related to decreased social support at both high and low stress levels (p < .01). Stress and social support are associated with depressive symptoms among dental students.
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Basic epidemiologic prevalence data are presented on sex differences in DSM-III-R major depressive episodes (MDE). The data come from the National Comorbidity Survey (NCS), the first survey in the U.S. to administer a structured psychiatric interview to a nationally representative sample of the general population. Consistent with previous research, women are approximately 1.7 times as likely as men to report a lifetime history of MDE. Age of onset analysis shows that this sex difference begins in early adolescence and persists through the mid-50s. Women also have a much higher rate of 12-month depression than men. However, women with a history of depression do not differ from men with a history of depression in either the probability of being chronically depressed in the past year or in the probability of having an acute recurrence in the past year. This means that the higher prevalence of 12-month depression among women than men is largely due to women having a higher risk of first onset. The implications of these results for future research are discussed in a closing section of the paper.
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To give an update on epidemiological findings on sex differences in the prevalence of unipolar depression and putative risk factors. Systematic review of the literature. Recent epidemiological research yields additional evidence for a female preponderance in unipolar depression, holding true across different cultural settings. Current explanations include artefacts, genetic, hormonal, psychological and psychosocial risk factors. Rather consistently, intrapsychic and psychosocial gender role related risk factors have been identified which may contribute to the higher depression risk in women. Gender role aspects are also reflected in endocrine stress reactions and possibly influence associated neuropsychological processes. There is a need for more integrative models taking into account psychological, psychosocial, and macrosocial risk factors as well as their interactions, which also connect these factors with physiological and endocrine responses. Furthermore, it is conceivable that across the life span, as well as across cultural settings, individual risk factors will add with varying emphasis to the higher prevalence of depression in women.
Levels of Anxiety, Depression and Social Support Perception in Students of Dentistry
  • Figueras A.