Nurse Education Today 34 (2014) e7–e12
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Prevalence and correlates of depression among college nursing students in China Ying Xu a,1, Xinli Chi b,1, Shaofeng Chen c, Juan Qi a, Pide Zhang a, Yi Yang a,⁎ a b c
Department of Epidemiology and Biostatistics, School of Public Health, Guangdong Pharmaceutical University, Jianghai Road 283, Haizhu District of Guangzhou, Guangzhou, China Division of Learning, Development and Diversity, Faculty of Education, University of Hong Kong, China Division of Student Affairs, Guangdong Pharmaceutical University, Guangzhou, China
a r t i c l e
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Article history: Accepted 23 October 2013 Keywords: Depression Center for Epidemiological Studies Depression Scale College nursing students Prevalence Risk factors
s u m m a r y This study aims to assess the prevalence of depression and examine potential risk factors correlated to depression among nursing college students in China. Between September and November 2012, a total of 763 college nursing students were randomly selected to participate in a survey, which included the Center for Epidemiologic Studies Depression Scale (CES-D). The result showed that 22.9% (95% CI: 20.0%–25.9%) of participants reported high score on the CES-D (16 or above). Risk factors significantly associated with depression in the univariate analysis were academic performance, academic stress, interest in majors, occupational future, interpersonal relationship, frequency of exercise, self-reported health status, social support, educational level of father, relationship with parents and making decisions without interference by parents. Backward multivariate logistic regression analysis revealed that lower academic stress, and better occupational future were strongly related to lower risk of depression, followed by active use of social support, full making decision power, better relationship with father and higher self-reported health status. The findings suggested that in order to prevent depression among college nursing students, school- and family-based strategies should be developed and implemented. Crown Copyright © 2013 Published by Elsevier Ltd. All rights reserved.
Introduction Depression is considered as a multi-problematic disorder that leads to impairment in inter-personal, social, and occupational functioning and is often associated with suicide among college students (Farabaugh et al., 2012; Ibrahim et al., 2013; Wilcox et al., 2010), and even as the greatest risk factor for suicide and a logical starting point with respect to identification of at-risk individuals (Konick and Gutierrez, 2005). For example, in 2006, the American College Health Association reported that 10% of college students seriously considered suicide and nearly suffered from significant depression. About 95% of students who commit suicide are clinically depressed, causing great suffering not only to themselves, but also to family members and people living around them. Therefore, in recent years, a great deal of attention has been placed on the prevalence and correlates of depression in college students worldwide (Aselton, 2012; Christensson et al., 2011).
⁎ Corresponding author at: School of Public Health, Guangdong Pharmaceutical University, Jianghai Road 283, Guangzhou 510310, China. Tel.: +86 13560450852; fax: + 86 2034055121. E-mail address: [email protected] (Y. Yang). 1 Contributed equally to this work and share the first authorship.
In light of prior studies, the prevalence of depression among college students varies largely across settings, depending on cultural backgrounds and study instruments (Ibrahim et al., 2013). Several studies have found that the rates of depression ranges from 7.6% to 22% among American and Indian young adults (Roberts et al., 2010; Sidana et al., 2012) and from 3.7% to 14.8% among Chinese college students (Jin et al., 2009). Furthermore, a review paper of Herman et al. (2011) showed that the prevalence of depression in the three largest U.S. ethno racial groups (African American, European American, and Hispanic) was conflicting. In this review, some studies found the levels of depressive symptoms among African Americans or Hispanics were higher than European Americans, while other studies demonstrated no differences or the differences varied depending on how depression was defined. Being in the medical field, nurses are faced with heavier academic pressure and psychological stressors and future medical practice. They are at a higher risk for depression as other professions in the same field (Ibrahim et al., 2013; Quince et al., 2012; Sidana et al., 2012). Nursing students are likely to become nurses, with occupational stress and the ambiguities of the profession, who most directly and frequently interact with patients and affect those patients by their behavior and attitudes. Therefore, their wellbeing cannot be taken lightly. Some studies have indicated that depression may decrease the function of nurses and disturbs the nurse–patient's relationship (Ahmadi et al., 2004; Uras et al., 2012). Depression among nurses has
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Y. Xu et al. / Nurse Education Today 34 (2014) e7–e12
attracted great attention from hospital and society (Christensson et al., 2011; Furegato et al., 2008; Lawlor et al., 2005). To our knowledge, there are limited studies on depression regarding prevalence and correlates among college nursing students in China (Ni et al., 2010). Notably, the medical education systems are diverse in different countries (Hsieh et al., 2011). In China, majority of the nursing students are female and fresh graduates from senior or junior school, aged from 16 to 25 and not married. This population of nursing students is very different from the participants who are married, and/or with prior work experiences in other studies (Christensson et al., 2011; Furegato et al., 2008; Lawlor et al., 2005). Therefore, there is a need to assess the prevalence and risk factors of depression among contemporary nursing students in China. Thus, this study aims to examine the prevalence of depression and to identify various possible factors (e.g. family socioeconomic status, academic, career prospect, social support as well as self evaluation of health status) related to depression in Chinese college nursing students. Methods Participants A cross-sectional design was used in this study and the students were randomly selected by multi-stage cluster sampling approach. Firstly, two out of the six nursing colleges in six medical universities in Guangzhou of Guangdong Province, south of China were selected. Secondly, five and fifteen classes were sampled in the two selected nursing colleges respectively, which corresponded to 80% of the students, and finally a total of 763 students from the 20 classes were invited to participate in the study. This study was approved by the administrative committee of the two participating universities. Between September and November 2012, the survey was administered to collect personal information, family background and social support of participants. The self-report questionnaire was required to complete in the classroom where students met for school activities. The students received explanations about the study objectives and their right to withdraw participation, and were informed how to complete the forms by the trained staffs. Participants were assured that their responses would be confidential and anonymous. All those enrolled in this study were compensated with a little gift in appreciation of their participation. A total of 763 students were enrolled in this study, of which 34 students provided incomplete questionnaire. The final number of data included in the multivariate model analysis was 729. Among all of the respondents, 661 students (86.6%) were females and 102 students (13.4%) were males. The grade distribution within the group was as follows: 279 (36.6%) were Year 1 nursing students, 295 (38.7%) were Year 2 nursing students, 146 (19.1%) were Year 3 nursing students and 43 (5.6%) were Year 4 nursing students. Instruments A questionnaire of the Center for Epidemiologic Studies Depression Scale (CES-D) was administered to the students. Each of the 20 items on the CES-D is rated on a four-point scale ranging from “rarely or none of the time” (value = 0) to “most or all of the time” (value = 3). Respondents are asked to rate their feelings during the past week on each item. The sum of the response scores ranges from 0 to 60. In the current sample, CES-D scales showed good internal consistency reliability as measured by Spearman–Brown and Cronbach's Alpha, with coefficients of 0.740 and 0.829, respectively. Participants were classified as depressed or non-depressed based on the traditional cutoff (CES-D N = 16) which indicated mild to moderate depression. This study also collected personal information (sex, single-child or not, living place before college [urban or rural area], interpersonal relationship, frequency of exercise, self-evaluated scores of health status),
academic related information (grade, academic performance, study stress, interest in majors, career prospects), family background (educational level of parents and family income, participants' relationship with their parents and their decision-making power without interference by parents), and attained social support (objective support [the range of score was 6–24], subjective support [the range of score was 0–18] and use of support [the range of score was 3–12]). All of these variables were classified into 2 or 3 or 4 categories (shown in Table 1). Statistical Analysis Chi-square analysis was performed to examine the association between depression and categorical variables; while, t-test was used for continuous variables. Multivariable logistical regression model by backward method (pout b 0.10) was used to estimate the association between statistically significant variables (p b 0.05) in the chi-square/ t-test analysis and depression. Odds ratios (OR) with 95% confidence interval (CI) were reported to determine the strength of association of these potential factors with depression. Data were analyzed using SPSS16.0 for windows (SPSS Inc., Chicago, IL) and p-value b 0.05 was considered significant. Results The overall prevalence of depression in the college nursing students was found to be 22.9% (95%CI: 20.0%–25.9%). In males, the prevalence was 17.6% (14.7%–20.5%), lower than 23.8% (15.5%–32.1%) in females. The mean score of CES-D was 2.5 times higher in the depressed group (CES-D scored 16 or above) than in the non-depressed group (21.5 ± 4.94 vs. 8.4 ± 4.01, p b 0.001). In the univariate analysis, 16 variables were observed to be significantly associated with less depression (all p-values b 0.05): better academic performance, less academic stress, greater interest in majors, feeling better for career prospects, better interpersonal relationship, higher frequency of exercise, educational level of father of more than 9 years, better relationship with parents and enjoying their full right to make divisions, higher self-evaluated score of health status and higher sum scores of attained social support including objective, subjective and use of support. The other variables, including gender, grade, single child or not, living place before college, educational level of mother and family monthly-income were non-significant risk factors for depression (all p-values N 0.05) (Table 1). By using backward method, 9 out of the above 16 significant variables were selected to be included in the multivariate logistic model according to pout b 0.10. Compared to pre-adjustment, the strength of associations of the 9 variables with depression was attenuated and their ORs ranged from 0.196 to 0.947. The academic stress and career prospects were the strongest predictors of depression, followed by making decisions without interference by mother and relationship with father. Additionally, effective social support and modest or less subjective support could help to decrease depression. A better selfreported health status was associated with less depression. The association between frequency of exercise and educational level of parents with depression was not significant in the multivariate logistic model (Table 2). Discussion This study showed that 22.9% participants had depressive symptoms. Poor perspective toward career prospect and stress from academic performance strongly increased the rate of depression among college nursing students. Having a good relationship with parents and making decisions without interference by parents were negatively associated with depression. Other risk factors such as frequency of exercise, self-reported health status, parents' education level, subjective social support, interest toward their major, and gender were weakly associated
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Table 1 The association between socio-demographic characteristics, education and family related factors with depression in Chinese nursing college students. Non-depressed (CES-D b 16)
Depressed (CES-D N = 16)
χ2/t
p
8.4 ± 4.01
21.5 ± 4.94
35.974
b0.001
1.863
0.172
102 (13.4) 661 (86.6)
84 (82.4) 504 (76.2)
18 (17.6) 157 (23.8) 0.969
0.809
279 (36.6) 295 (38.7) 146 (19.1) 43 (5.7)
219 (78.5) 226 (76.6) 112 (76.7) 31 (72.1)
60 (21.5) 69 (23.4) 34 (23.3) 12 (27.9) 1.450
0.229
99 (13.0) 660 (87.0)
81 (81.8) 504 (76.4)
18 (18.2) 156 (23.6) 0.241
0.623
562 (74.7) 190 (25.3)
m431 (76.7) 149 (78.4)
131 (23.3) 41 (21.6) 9.602
0.008
218 (28.7) 416 (54.7) 126 (16.6)
176 (80.7) 325 (78.1) 84 (66.7)
42 (19.3) 91 (21.9) 42 (33.3) 12.869
0.002
379 (49.7) 370 (48.5) 14 (1.8)
272 (71.8) 303 (81.9) 13 (92.9)
107 (28.2) 67 (18.1) 1 (7.1) 6.881
0.032
306 (40.1) 386 (50.7) 70 (9.2)
249 (81.4) 290 (75.1) 48 (68.6)
57 (18.6) 96 (24.9) 22 (31.4) 16.907
b0.001
606 (79.4) 142 (18.6) 15 (2.0)
475 (78.4) 108 (76.1) 5 (33.3)
131 (21.6) 34 (23.9) 10 (66.7) 27.253
b0.001
398 (52.1) 365 (47.9)
337 (84.7) 251 (68.8)
61 (15.3) 114 (31.2) 15.360
0.002
98 (12.9) 499 (65.7) 117 (15.4) 45 (6.0)
67 (68.4) 376 (75.4) 102 (87.2) 40 (88.9) 87.5 ± 64.46
31 (31.6) 123 (24.6) 15 (12.8) 5 (11.1) 72.5 ± 15.13
3.021
0.003
6.8 ± 2.23 16.4 ± 2.09 8.4 ± 1.58 31.6 ± 4.31
6.2 ± 2.33 15.3 ± 2.24 7.7 ± 1.55 29.2 ± 4.38
3.101 5.990 4.824 6.321
0.002 b0.001 b0.001 b0.001
4.651
0.031
439 (58.5) 312 (41.5)
325 (74.0) 252 (80.8)
114 (26.0) 60 (19.2) 2.477
0.116
574 (76.1) 180 (23.9)
433 (75.4) 146 (81.1)
141 (24.6) 34 (18.9) 1.890
0.389
503 (66.4) 177 (23.4) 77 (10.2)
381 (75.7) 143 (80.8) 59 (76.6)
122 (24.3) 34 (19.2) 18 (23.4) 23.018
b0.001
568 (75.7) 182 (24.3)
460 (81.0) 116 (63.7)
108 (19.0) 66 (36.3) 20.222
b0.001
666 (88.0) 91 (12.0)
529 (79.4) 53 (58.2)
137 (20.6) 38 (41.8) 43.526
b0.001
237 (31.6) 229 (30.6) 198 (26.4) 85 (11.4)
203 (85.7) 186 (81.2) 141 (71.2) 45 (52.9)
34 (14.3) 43 (18.8) 57 (28.8) 40 (47.1) 38.863
b0.001
270 (35.8) 286 (37.8) 141 (18.7) 58 (7.7)
230 (85.2) 227 (79.4) 91 (64.5) 32 (55.2)
40 (14.8) 59 (20.6) 50 (35.5) 26 (44.8)
n (%) CES-D score b Personal information Sexa Male Female Grade a Grade 1 Grade 2 Grade 3 Grade 4 Single childa Yes No Living place before collegea Rural Urban Academic performancea Better Medium Worse Academic stressa Greater Medium Less Interest in their majora Greater Medium Less Perspective toward future careera Good Fair Poor Interpersonal relationshipa Good Fair or poor Frequency of exercisea No 1–2 days/week 3–5 days/week N5 days/week Self-reported health statusb Attained social support Objective supportb Subjective supportb Use of supportb Total supportb Family background Educational level of fathera b9 years N = 9 years Educational level of mothera b9 years N = 9 years Family monthly-income (RMB)a b2000 2000–3999 N = 4000 Relationship with fathera Good Fair or bad Relationship with mothera Good Fair or bad Making decisions without interference by fathera Always Often Sometimes Occasionally Making decisions without interference by mothera Always Often Sometimes Occasionally a b
Categorical variables were presented as n (%). Continuous variables were presented as mean ± SD.
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Table 2 Odd ratios (95%CI) of depression for socio-demographic characteristics, education and family related factors in logistic regression models. Univariate modela
Academic stress Greater Medium Less Perspective toward future career Good Fair Poor Interpersonal relationship Good Fair or poor Self-reported health status Attained social support Subjective support Use of support Family background Relationship with father Good Fair or bad Relationship with mother Good Fair or bad Making decisions without interference by mother Always Often Sometimes Occasionally a b
Multivariate modelb
OR (95%CI)
p
OR (95%CI)
1 0.230 (0.030–1.781) 0.511 (0.353–0.740)
0.159 b0.001
1 0.196 (0.022–1.728) 0.484 (0.314–0.744)
p
0.142 0.001
0.151 (0.053–0.433) 0.171 (0.056–0.519) 1
b0.001 0.002
0.213 (0.066–0.684) 0.198 (0.058–0.678) 1
0.009 0.010
0.440 (0.304–0.637) 1 0.937 (0.921–0.953)
b0.001
0.077
b0.001
0.666 (0.424–1.045) 1 0.947 (0.930–0.964)
b0.001
0.787 (0.726–0.854) 0.752 (0.666–0.849)
b0.001 b0.001
0.905 (0.816–1.003) 0.860 (0.748–0.989)
0.057 0.035
0.337 (0.230–0.494) 1
b0.001
0.446 (0.271–0.736) 1
0.002
0.375 (0.234–0.600) 1
b0.001
0.547 (0.270–1.110) 1
0.095
0.190 (0.100–0.361) 0.330 (0.181–0.601) 0.561 (0.296–1.062) 1
b0.001 b0.001 0.076
0.298 (0.134–0.666) 0.335 (0.156–0.720) 0.506 (0.237–1.083) 1
0.003 0.005 0.079
Only one factor was included in the univariate model. The above all 9 factors in this table were simultaneously included in the multivariate model by backward method according to pout b 0.10.
with depression. Hence, the findings of this study suggested that in order to prevent and treat depression among Chinese nursing students, health care profession can focus on helping students to manage academic stress and improve their perspective toward their future career. Additionally, they can also involve the parents of the students by helping them to improve their family relationship. The present study indicated that 22.9% of the participants had high level of depression (16 or above of CES-D scores), which was similar with the findings from other countries like Iran (22.1%) and Korea (19.4%) (Ahmadi et al., 2004; Furegato et al., 2008), however, the depression rate among medical students in North America was reported to be slightly lower (13–24%) (Dyrbye et al., 2006). As stated earlier, majority of nurses in China are females who bear an important role in the health care system. The high demands of their job by taking care of the sick, and the frequent interaction with patients may have caused greater psychological problems compared to other students in the medical field. By and large, the reason of a high rate of depression among nurses is not completely known; however, it is acknowledged that the etiology is multifactorial (Harris and Penrose-Wall, 2001). In addition to the above reason, the different depression scales including Beck Depression Inventory (BDI), CES-D, Hamilton, and Zung, may partly explain the disparity between these studies, because these depression scales had fewer common specific depression symptom factors than expected which were reported by Shafer (2006). Furthermore, the season when the depression survey was administrated might partly cause the differences in the prevalence of depression among these studies. Studies showed that the secretion of neuromodulators such as serotonin could be affected by seasons (Perez et al., 2013; Winthorst et al., 2011). Lastly, socio-demographic factors may also have resulted in the differences in the level of depression (Herman et al., 2011). Consistent with previous studies conducted among Chinese and other Asian medical students (Han et al., 2013; Menezes et al., 2012; Ni et al., 2010; Peng et al., 2010; Yusoff et al., 2013), the results of the present study showed that there was the strong relationship between
academic stress and concerns of career prospects with depression among nursing students. Another study (Aselton, 2012) conducted among American college students who were diagnosed with depression, by using Seidman's guide to in-depth qualitative interviews, found that the sources of stress included academic problems and career concerns. The above findings might support that academic pressure is a ‘normal’ and universal issue which is commonly experienced by Eastern and Western college students including college nursing students. In today's rat race society, not to mention the rapid economic transformation in China, college students usually face greater academic overload and increasingly competitive environment with fewer job opportunities at graduation than ever before, so they must strive for excellence in academic performance in order to reach their parents' high expectations and arm themselves with skilled abilities in the future, which may have increased their stress level and led to depression (Peng et al., 2010). Moreover, compared to clinicians' professionals comparable in years of education, nursing work is still inferior because of Chinese people's prejudice which further has added the worries and stress about their career prospects and resulted in the occurrence of depressive symptoms. In turn, the worries and stress may further influence academic performance and well-being (Ni et al., 2010). Thus, stress management might be an important skill for nursing students to acquire while they are in college. This could be achieved through effective interventions and education by enhancing coping strategies and mental strengths. One such example is to form peer discussion groups, which can aim to help students to process conflict and unmask the realization that their plight is not unique. Many studies have showed that family harmony and family support play an important role in suicide ideation and depression among college students (Han et al., 2013; Harris and Molock, 2000; Menezes et al., 2012). Lower levels of family cohesion and support and higher levels of parent–adolescent conflict were related to the higher prevalence of depression and suicide ideation. Our results strongly supported the aforementioned findings, which showed that a harmonious family environment (e.g. good relationship between parents and children and
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democratic parenting styles, decision-making power without interference of parents) might cultivate better personality traits of adolescents and young people. The benignant process ultimately contributes to the solution of depressive episodes. Thus, a family-based therapy as a treatment for depression has been proposed by some investigators (Moon and Rao, 2010; Restifo and Bogels, 2009; Sander and McCarty, 2005). In a multivariate model, the use of social support and higher selfevaluated score of health status were also associated with the decreased risk of depression, although the associations were weaker, compared to other factors related to depression. Previous studies reported that the type of coping strategies of individuals could affect both physical and mental health (Wheaton, 1985; Wolf, 1994). Generally speaking, passive coping is positively related to psychological symptoms, while active coping and support seeking are correlated with less mental health problems. The finding in this study also showed that the effective use of support from outside could partially alleviate the depression which was consistent with the result from a large sample of 10,140 medical students in Anhui Province of China (Sun et al., 2011). Additionally, the result also showed that there was a correlation between mental disorder and physical health problems. A possible explanation to this finding is that poor evaluation of physical health status might cause the negative influence on their mood and academic performance, and even induce perception of stress which in turn had increased the risk of depression. In addition, the interest in their major showed no significant association with depression which was consistent with a study conducted among Korean and Chinese nursing students (Lee et al., 2011). Furthermore, the significant association between frequency of exercise and depression was also not observed in the present study which was opposite with the findings of previous studies (Hawker, 2012; Tyson et al., 2010). The differences might be partly explained by the different covariates adjusted for in the data analysis, no use of objective tool in measuring physical activity, lower physical activity compared to their counterparts in the developed countries, and age profile limited to 17 to 22 year old individuals in this study. In the present study, family income per month and educational level of parents were also nonsignificantly associated with depression. Currently, the association between family socio-demographic characteristics (primarily presented by family income situation and educational levels of parents) and depression among medical students is not established (Sidana et al., 2012; Sun et al., 2011) and further research is needed. Due to the limited number of male participants (13.4%) in this study, we were not able to explore gender differences in depth. Hence, more work is required to investigate the differences between male and female nursing students in regard to some of the associations observed in the present study. A potential limitation of this study is its cross-sectional design, which has made it difficult to make reference in regard to the causality of depression. For example, a study indicated that depression was an important cause of poor academic performance among college students (Hysenbegasi et al., 2005). A follow-up study in the future may be used to determine the causal relationship between depression and risk factors identified in the current study. Secondly, due to the nature of exclusively self-reported measures, the results of this study have to be cautiously interpreted. However, participants in this study were ensured confidentiality by using anonymous reports and were told that no sanctions were connected to the answers. The procedure can decrease the possibility of dishonesty. Thirdly, the results of this study were parts of the research, which examined the association on dietary pattern and depression among Chinese college students. As a result, some variables, for example physical activity and stress level reported in the present study, could have been collected differently with higher precision and accuracy. Future research is needed to further understand the association between depression and the risk factors stated in the present study. Finally, less number of male nursing students in the current study may have reduced the power to detect gender differences. However, the large sample size of nursing college students, adequate control for
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confounding factors and the use of valid scale to identify depressive symptoms among the college nursing students of the present study might have warranted the validity of the study. Conclusions Although much work remains to be done before one can determine the causality of depression among nursing students, the current study definitely provided valuable contribution to the literature. This study was able to identify risk factors, which were significantly related to depression among nursing students in China. This study also suggested several important practical implications for the health care profession or the authorities of medical college to consider suitable strategies at the familial, college and societal level to deal with the depression issue, so that the nursing students could be competent nurses with healthy mental status for the nursing work force in China. Contributors Authors Ying Xu and Yi Yang designed the study and wrote the protocol. Authors Juan Qi, Shaofeng Chen and Pide Zhang undertook the collection of data. Authors Ying Xu and Xinli Chi wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript. Conflicts of Interest/Disclosure Statement All authors have no personal or financial conflicts of interest to declare. Acknowledgments The project was funded by the Foundation of the Ministry of Education of China for Young Teachers [Grant no: 11YJCZH204]. The authors would like to thank all instructors and their assistants for their help during the course of the investigation, and also all of the operators who contributed to the study. References Ahmadi, J., Toobaee, S., Alishahi, M., 2004. Depression in nursing students. J. Clin. Nurs. 13 (1), 124. Aselton, P., 2012. Sources of stress and coping in American college students who have been diagnosed with depression. J. Child Adolesc. Psychiatr. Nurs. 25 (3), 119–123. Christensson, A., Vaez, M., Dickman, P.W., Runeson, B., 2011. Self-reported depression in first-year nursing students in relation to socio-demographic and educational factors: a nationwide cross-sectional study in Sweden. Soc. Psychiatry Psychiatr. Epidemiol. 46 (4), 299–310. Dyrbye, L.N., Thomas, M.R., Shanafelt, T.D., 2006. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad. Med. 81 (4), 354–373. Farabaugh, A., Bitran, S., Nyer, M., Holt, D.J., Pedrelli, P., Shyu, I., Hollon, S.D., Zisook, S., Baer, L., Busse, W., Petersen, T.J., Pender, M., Tucker, D.D., Fava, M., 2012. Depression and suicidal ideation in college students. Psychopathology 45 (4), 228–234. Furegato, A.R., Santos, J.L., Silva, E.C., 2008. Depression among nursing students associated to their self-esteem, health perception and interest in mental health. Rev. Lat. Am. Enfermagem. 16 (2), 198–204. Han, C.S., Oliffe, J.L., Ogrodniczuk, J.S., 2013. Suicide among East Asians in North America: a scoping review. J. Ment. Health 22 (4), 361–371. Harris, T.L., Molock, S.D., 2000. Cultural orientation, family cohesion, and family support in suicide ideation and depression among African American college students. Suicide Life Threat. Behav. 30 (4), 341–353. Harris, M.F., Penrose-Wall, J., 2001. Mental distress or disorder? Med. J. Aust. 175 (Suppl.), S6–S7. Hawker, C.L., 2012. Physical activity and mental well-being in student nurses. Nurse Educ. Today 32 (3), 325–331. Herman, S., Archambeau, O.G., Deliramich, A.N., Kim, B.S., Chiu, P.H., Frueh, B.C., 2011. Depressive symptoms and mental health treatment in an ethnoracially diverse college student sample. J. Am. Coll. Health 59 (8), 715–720. Hsieh, Y.H., Hsu, C.Y., Liu, C.Y., Huang, T.L., 2011. The levels of stress and depression among interns and clerks in three medical centers in Taiwan — a cross-sectional study. Chang Gung Med. J. 34 (3), 278–285.
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Nurse Education Today journal homepage: www.elsevier.com/nedt
Prevalence and correlates of depression among college nursing students in China Ying Xu a,1, Xinli Chi b,1, Shaofeng Chen c, Juan Qi a, Pide Zhang a, Yi Yang a,⁎ a b c
Department of Epidemiology and Biostatistics, School of Public Health, Guangdong Pharmaceutical University, Jianghai Road 283, Haizhu District of Guangzhou, Guangzhou, China Division of Learning, Development and Diversity, Faculty of Education, University of Hong Kong, China Division of Student Affairs, Guangdong Pharmaceutical University, Guangzhou, China
a r t i c l e
i n f o
Article history: Accepted 23 October 2013 Keywords: Depression Center for Epidemiological Studies Depression Scale College nursing students Prevalence Risk factors
s u m m a r y This study aims to assess the prevalence of depression and examine potential risk factors correlated to depression among nursing college students in China. Between September and November 2012, a total of 763 college nursing students were randomly selected to participate in a survey, which included the Center for Epidemiologic Studies Depression Scale (CES-D). The result showed that 22.9% (95% CI: 20.0%–25.9%) of participants reported high score on the CES-D (16 or above). Risk factors significantly associated with depression in the univariate analysis were academic performance, academic stress, interest in majors, occupational future, interpersonal relationship, frequency of exercise, self-reported health status, social support, educational level of father, relationship with parents and making decisions without interference by parents. Backward multivariate logistic regression analysis revealed that lower academic stress, and better occupational future were strongly related to lower risk of depression, followed by active use of social support, full making decision power, better relationship with father and higher self-reported health status. The findings suggested that in order to prevent depression among college nursing students, school- and family-based strategies should be developed and implemented. Crown Copyright © 2013 Published by Elsevier Ltd. All rights reserved.
Introduction Depression is considered as a multi-problematic disorder that leads to impairment in inter-personal, social, and occupational functioning and is often associated with suicide among college students (Farabaugh et al., 2012; Ibrahim et al., 2013; Wilcox et al., 2010), and even as the greatest risk factor for suicide and a logical starting point with respect to identification of at-risk individuals (Konick and Gutierrez, 2005). For example, in 2006, the American College Health Association reported that 10% of college students seriously considered suicide and nearly suffered from significant depression. About 95% of students who commit suicide are clinically depressed, causing great suffering not only to themselves, but also to family members and people living around them. Therefore, in recent years, a great deal of attention has been placed on the prevalence and correlates of depression in college students worldwide (Aselton, 2012; Christensson et al., 2011).
⁎ Corresponding author at: School of Public Health, Guangdong Pharmaceutical University, Jianghai Road 283, Guangzhou 510310, China. Tel.: +86 13560450852; fax: + 86 2034055121. E-mail address: [email protected] (Y. Yang). 1 Contributed equally to this work and share the first authorship.
In light of prior studies, the prevalence of depression among college students varies largely across settings, depending on cultural backgrounds and study instruments (Ibrahim et al., 2013). Several studies have found that the rates of depression ranges from 7.6% to 22% among American and Indian young adults (Roberts et al., 2010; Sidana et al., 2012) and from 3.7% to 14.8% among Chinese college students (Jin et al., 2009). Furthermore, a review paper of Herman et al. (2011) showed that the prevalence of depression in the three largest U.S. ethno racial groups (African American, European American, and Hispanic) was conflicting. In this review, some studies found the levels of depressive symptoms among African Americans or Hispanics were higher than European Americans, while other studies demonstrated no differences or the differences varied depending on how depression was defined. Being in the medical field, nurses are faced with heavier academic pressure and psychological stressors and future medical practice. They are at a higher risk for depression as other professions in the same field (Ibrahim et al., 2013; Quince et al., 2012; Sidana et al., 2012). Nursing students are likely to become nurses, with occupational stress and the ambiguities of the profession, who most directly and frequently interact with patients and affect those patients by their behavior and attitudes. Therefore, their wellbeing cannot be taken lightly. Some studies have indicated that depression may decrease the function of nurses and disturbs the nurse–patient's relationship (Ahmadi et al., 2004; Uras et al., 2012). Depression among nurses has
0260-6917/$ – see front matter Crown Copyright © 2013 Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2013.10.017
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attracted great attention from hospital and society (Christensson et al., 2011; Furegato et al., 2008; Lawlor et al., 2005). To our knowledge, there are limited studies on depression regarding prevalence and correlates among college nursing students in China (Ni et al., 2010). Notably, the medical education systems are diverse in different countries (Hsieh et al., 2011). In China, majority of the nursing students are female and fresh graduates from senior or junior school, aged from 16 to 25 and not married. This population of nursing students is very different from the participants who are married, and/or with prior work experiences in other studies (Christensson et al., 2011; Furegato et al., 2008; Lawlor et al., 2005). Therefore, there is a need to assess the prevalence and risk factors of depression among contemporary nursing students in China. Thus, this study aims to examine the prevalence of depression and to identify various possible factors (e.g. family socioeconomic status, academic, career prospect, social support as well as self evaluation of health status) related to depression in Chinese college nursing students. Methods Participants A cross-sectional design was used in this study and the students were randomly selected by multi-stage cluster sampling approach. Firstly, two out of the six nursing colleges in six medical universities in Guangzhou of Guangdong Province, south of China were selected. Secondly, five and fifteen classes were sampled in the two selected nursing colleges respectively, which corresponded to 80% of the students, and finally a total of 763 students from the 20 classes were invited to participate in the study. This study was approved by the administrative committee of the two participating universities. Between September and November 2012, the survey was administered to collect personal information, family background and social support of participants. The self-report questionnaire was required to complete in the classroom where students met for school activities. The students received explanations about the study objectives and their right to withdraw participation, and were informed how to complete the forms by the trained staffs. Participants were assured that their responses would be confidential and anonymous. All those enrolled in this study were compensated with a little gift in appreciation of their participation. A total of 763 students were enrolled in this study, of which 34 students provided incomplete questionnaire. The final number of data included in the multivariate model analysis was 729. Among all of the respondents, 661 students (86.6%) were females and 102 students (13.4%) were males. The grade distribution within the group was as follows: 279 (36.6%) were Year 1 nursing students, 295 (38.7%) were Year 2 nursing students, 146 (19.1%) were Year 3 nursing students and 43 (5.6%) were Year 4 nursing students. Instruments A questionnaire of the Center for Epidemiologic Studies Depression Scale (CES-D) was administered to the students. Each of the 20 items on the CES-D is rated on a four-point scale ranging from “rarely or none of the time” (value = 0) to “most or all of the time” (value = 3). Respondents are asked to rate their feelings during the past week on each item. The sum of the response scores ranges from 0 to 60. In the current sample, CES-D scales showed good internal consistency reliability as measured by Spearman–Brown and Cronbach's Alpha, with coefficients of 0.740 and 0.829, respectively. Participants were classified as depressed or non-depressed based on the traditional cutoff (CES-D N = 16) which indicated mild to moderate depression. This study also collected personal information (sex, single-child or not, living place before college [urban or rural area], interpersonal relationship, frequency of exercise, self-evaluated scores of health status),
academic related information (grade, academic performance, study stress, interest in majors, career prospects), family background (educational level of parents and family income, participants' relationship with their parents and their decision-making power without interference by parents), and attained social support (objective support [the range of score was 6–24], subjective support [the range of score was 0–18] and use of support [the range of score was 3–12]). All of these variables were classified into 2 or 3 or 4 categories (shown in Table 1). Statistical Analysis Chi-square analysis was performed to examine the association between depression and categorical variables; while, t-test was used for continuous variables. Multivariable logistical regression model by backward method (pout b 0.10) was used to estimate the association between statistically significant variables (p b 0.05) in the chi-square/ t-test analysis and depression. Odds ratios (OR) with 95% confidence interval (CI) were reported to determine the strength of association of these potential factors with depression. Data were analyzed using SPSS16.0 for windows (SPSS Inc., Chicago, IL) and p-value b 0.05 was considered significant. Results The overall prevalence of depression in the college nursing students was found to be 22.9% (95%CI: 20.0%–25.9%). In males, the prevalence was 17.6% (14.7%–20.5%), lower than 23.8% (15.5%–32.1%) in females. The mean score of CES-D was 2.5 times higher in the depressed group (CES-D scored 16 or above) than in the non-depressed group (21.5 ± 4.94 vs. 8.4 ± 4.01, p b 0.001). In the univariate analysis, 16 variables were observed to be significantly associated with less depression (all p-values b 0.05): better academic performance, less academic stress, greater interest in majors, feeling better for career prospects, better interpersonal relationship, higher frequency of exercise, educational level of father of more than 9 years, better relationship with parents and enjoying their full right to make divisions, higher self-evaluated score of health status and higher sum scores of attained social support including objective, subjective and use of support. The other variables, including gender, grade, single child or not, living place before college, educational level of mother and family monthly-income were non-significant risk factors for depression (all p-values N 0.05) (Table 1). By using backward method, 9 out of the above 16 significant variables were selected to be included in the multivariate logistic model according to pout b 0.10. Compared to pre-adjustment, the strength of associations of the 9 variables with depression was attenuated and their ORs ranged from 0.196 to 0.947. The academic stress and career prospects were the strongest predictors of depression, followed by making decisions without interference by mother and relationship with father. Additionally, effective social support and modest or less subjective support could help to decrease depression. A better selfreported health status was associated with less depression. The association between frequency of exercise and educational level of parents with depression was not significant in the multivariate logistic model (Table 2). Discussion This study showed that 22.9% participants had depressive symptoms. Poor perspective toward career prospect and stress from academic performance strongly increased the rate of depression among college nursing students. Having a good relationship with parents and making decisions without interference by parents were negatively associated with depression. Other risk factors such as frequency of exercise, self-reported health status, parents' education level, subjective social support, interest toward their major, and gender were weakly associated
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Table 1 The association between socio-demographic characteristics, education and family related factors with depression in Chinese nursing college students. Non-depressed (CES-D b 16)
Depressed (CES-D N = 16)
χ2/t
p
8.4 ± 4.01
21.5 ± 4.94
35.974
b0.001
1.863
0.172
102 (13.4) 661 (86.6)
84 (82.4) 504 (76.2)
18 (17.6) 157 (23.8) 0.969
0.809
279 (36.6) 295 (38.7) 146 (19.1) 43 (5.7)
219 (78.5) 226 (76.6) 112 (76.7) 31 (72.1)
60 (21.5) 69 (23.4) 34 (23.3) 12 (27.9) 1.450
0.229
99 (13.0) 660 (87.0)
81 (81.8) 504 (76.4)
18 (18.2) 156 (23.6) 0.241
0.623
562 (74.7) 190 (25.3)
m431 (76.7) 149 (78.4)
131 (23.3) 41 (21.6) 9.602
0.008
218 (28.7) 416 (54.7) 126 (16.6)
176 (80.7) 325 (78.1) 84 (66.7)
42 (19.3) 91 (21.9) 42 (33.3) 12.869
0.002
379 (49.7) 370 (48.5) 14 (1.8)
272 (71.8) 303 (81.9) 13 (92.9)
107 (28.2) 67 (18.1) 1 (7.1) 6.881
0.032
306 (40.1) 386 (50.7) 70 (9.2)
249 (81.4) 290 (75.1) 48 (68.6)
57 (18.6) 96 (24.9) 22 (31.4) 16.907
b0.001
606 (79.4) 142 (18.6) 15 (2.0)
475 (78.4) 108 (76.1) 5 (33.3)
131 (21.6) 34 (23.9) 10 (66.7) 27.253
b0.001
398 (52.1) 365 (47.9)
337 (84.7) 251 (68.8)
61 (15.3) 114 (31.2) 15.360
0.002
98 (12.9) 499 (65.7) 117 (15.4) 45 (6.0)
67 (68.4) 376 (75.4) 102 (87.2) 40 (88.9) 87.5 ± 64.46
31 (31.6) 123 (24.6) 15 (12.8) 5 (11.1) 72.5 ± 15.13
3.021
0.003
6.8 ± 2.23 16.4 ± 2.09 8.4 ± 1.58 31.6 ± 4.31
6.2 ± 2.33 15.3 ± 2.24 7.7 ± 1.55 29.2 ± 4.38
3.101 5.990 4.824 6.321
0.002 b0.001 b0.001 b0.001
4.651
0.031
439 (58.5) 312 (41.5)
325 (74.0) 252 (80.8)
114 (26.0) 60 (19.2) 2.477
0.116
574 (76.1) 180 (23.9)
433 (75.4) 146 (81.1)
141 (24.6) 34 (18.9) 1.890
0.389
503 (66.4) 177 (23.4) 77 (10.2)
381 (75.7) 143 (80.8) 59 (76.6)
122 (24.3) 34 (19.2) 18 (23.4) 23.018
b0.001
568 (75.7) 182 (24.3)
460 (81.0) 116 (63.7)
108 (19.0) 66 (36.3) 20.222
b0.001
666 (88.0) 91 (12.0)
529 (79.4) 53 (58.2)
137 (20.6) 38 (41.8) 43.526
b0.001
237 (31.6) 229 (30.6) 198 (26.4) 85 (11.4)
203 (85.7) 186 (81.2) 141 (71.2) 45 (52.9)
34 (14.3) 43 (18.8) 57 (28.8) 40 (47.1) 38.863
b0.001
270 (35.8) 286 (37.8) 141 (18.7) 58 (7.7)
230 (85.2) 227 (79.4) 91 (64.5) 32 (55.2)
40 (14.8) 59 (20.6) 50 (35.5) 26 (44.8)
n (%) CES-D score b Personal information Sexa Male Female Grade a Grade 1 Grade 2 Grade 3 Grade 4 Single childa Yes No Living place before collegea Rural Urban Academic performancea Better Medium Worse Academic stressa Greater Medium Less Interest in their majora Greater Medium Less Perspective toward future careera Good Fair Poor Interpersonal relationshipa Good Fair or poor Frequency of exercisea No 1–2 days/week 3–5 days/week N5 days/week Self-reported health statusb Attained social support Objective supportb Subjective supportb Use of supportb Total supportb Family background Educational level of fathera b9 years N = 9 years Educational level of mothera b9 years N = 9 years Family monthly-income (RMB)a b2000 2000–3999 N = 4000 Relationship with fathera Good Fair or bad Relationship with mothera Good Fair or bad Making decisions without interference by fathera Always Often Sometimes Occasionally Making decisions without interference by mothera Always Often Sometimes Occasionally a b
Categorical variables were presented as n (%). Continuous variables were presented as mean ± SD.
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Table 2 Odd ratios (95%CI) of depression for socio-demographic characteristics, education and family related factors in logistic regression models. Univariate modela
Academic stress Greater Medium Less Perspective toward future career Good Fair Poor Interpersonal relationship Good Fair or poor Self-reported health status Attained social support Subjective support Use of support Family background Relationship with father Good Fair or bad Relationship with mother Good Fair or bad Making decisions without interference by mother Always Often Sometimes Occasionally a b
Multivariate modelb
OR (95%CI)
p
OR (95%CI)
1 0.230 (0.030–1.781) 0.511 (0.353–0.740)
0.159 b0.001
1 0.196 (0.022–1.728) 0.484 (0.314–0.744)
p
0.142 0.001
0.151 (0.053–0.433) 0.171 (0.056–0.519) 1
b0.001 0.002
0.213 (0.066–0.684) 0.198 (0.058–0.678) 1
0.009 0.010
0.440 (0.304–0.637) 1 0.937 (0.921–0.953)
b0.001
0.077
b0.001
0.666 (0.424–1.045) 1 0.947 (0.930–0.964)
b0.001
0.787 (0.726–0.854) 0.752 (0.666–0.849)
b0.001 b0.001
0.905 (0.816–1.003) 0.860 (0.748–0.989)
0.057 0.035
0.337 (0.230–0.494) 1
b0.001
0.446 (0.271–0.736) 1
0.002
0.375 (0.234–0.600) 1
b0.001
0.547 (0.270–1.110) 1
0.095
0.190 (0.100–0.361) 0.330 (0.181–0.601) 0.561 (0.296–1.062) 1
b0.001 b0.001 0.076
0.298 (0.134–0.666) 0.335 (0.156–0.720) 0.506 (0.237–1.083) 1
0.003 0.005 0.079
Only one factor was included in the univariate model. The above all 9 factors in this table were simultaneously included in the multivariate model by backward method according to pout b 0.10.
with depression. Hence, the findings of this study suggested that in order to prevent and treat depression among Chinese nursing students, health care profession can focus on helping students to manage academic stress and improve their perspective toward their future career. Additionally, they can also involve the parents of the students by helping them to improve their family relationship. The present study indicated that 22.9% of the participants had high level of depression (16 or above of CES-D scores), which was similar with the findings from other countries like Iran (22.1%) and Korea (19.4%) (Ahmadi et al., 2004; Furegato et al., 2008), however, the depression rate among medical students in North America was reported to be slightly lower (13–24%) (Dyrbye et al., 2006). As stated earlier, majority of nurses in China are females who bear an important role in the health care system. The high demands of their job by taking care of the sick, and the frequent interaction with patients may have caused greater psychological problems compared to other students in the medical field. By and large, the reason of a high rate of depression among nurses is not completely known; however, it is acknowledged that the etiology is multifactorial (Harris and Penrose-Wall, 2001). In addition to the above reason, the different depression scales including Beck Depression Inventory (BDI), CES-D, Hamilton, and Zung, may partly explain the disparity between these studies, because these depression scales had fewer common specific depression symptom factors than expected which were reported by Shafer (2006). Furthermore, the season when the depression survey was administrated might partly cause the differences in the prevalence of depression among these studies. Studies showed that the secretion of neuromodulators such as serotonin could be affected by seasons (Perez et al., 2013; Winthorst et al., 2011). Lastly, socio-demographic factors may also have resulted in the differences in the level of depression (Herman et al., 2011). Consistent with previous studies conducted among Chinese and other Asian medical students (Han et al., 2013; Menezes et al., 2012; Ni et al., 2010; Peng et al., 2010; Yusoff et al., 2013), the results of the present study showed that there was the strong relationship between
academic stress and concerns of career prospects with depression among nursing students. Another study (Aselton, 2012) conducted among American college students who were diagnosed with depression, by using Seidman's guide to in-depth qualitative interviews, found that the sources of stress included academic problems and career concerns. The above findings might support that academic pressure is a ‘normal’ and universal issue which is commonly experienced by Eastern and Western college students including college nursing students. In today's rat race society, not to mention the rapid economic transformation in China, college students usually face greater academic overload and increasingly competitive environment with fewer job opportunities at graduation than ever before, so they must strive for excellence in academic performance in order to reach their parents' high expectations and arm themselves with skilled abilities in the future, which may have increased their stress level and led to depression (Peng et al., 2010). Moreover, compared to clinicians' professionals comparable in years of education, nursing work is still inferior because of Chinese people's prejudice which further has added the worries and stress about their career prospects and resulted in the occurrence of depressive symptoms. In turn, the worries and stress may further influence academic performance and well-being (Ni et al., 2010). Thus, stress management might be an important skill for nursing students to acquire while they are in college. This could be achieved through effective interventions and education by enhancing coping strategies and mental strengths. One such example is to form peer discussion groups, which can aim to help students to process conflict and unmask the realization that their plight is not unique. Many studies have showed that family harmony and family support play an important role in suicide ideation and depression among college students (Han et al., 2013; Harris and Molock, 2000; Menezes et al., 2012). Lower levels of family cohesion and support and higher levels of parent–adolescent conflict were related to the higher prevalence of depression and suicide ideation. Our results strongly supported the aforementioned findings, which showed that a harmonious family environment (e.g. good relationship between parents and children and
Y. Xu et al. / Nurse Education Today 34 (2014) e7–e12
democratic parenting styles, decision-making power without interference of parents) might cultivate better personality traits of adolescents and young people. The benignant process ultimately contributes to the solution of depressive episodes. Thus, a family-based therapy as a treatment for depression has been proposed by some investigators (Moon and Rao, 2010; Restifo and Bogels, 2009; Sander and McCarty, 2005). In a multivariate model, the use of social support and higher selfevaluated score of health status were also associated with the decreased risk of depression, although the associations were weaker, compared to other factors related to depression. Previous studies reported that the type of coping strategies of individuals could affect both physical and mental health (Wheaton, 1985; Wolf, 1994). Generally speaking, passive coping is positively related to psychological symptoms, while active coping and support seeking are correlated with less mental health problems. The finding in this study also showed that the effective use of support from outside could partially alleviate the depression which was consistent with the result from a large sample of 10,140 medical students in Anhui Province of China (Sun et al., 2011). Additionally, the result also showed that there was a correlation between mental disorder and physical health problems. A possible explanation to this finding is that poor evaluation of physical health status might cause the negative influence on their mood and academic performance, and even induce perception of stress which in turn had increased the risk of depression. In addition, the interest in their major showed no significant association with depression which was consistent with a study conducted among Korean and Chinese nursing students (Lee et al., 2011). Furthermore, the significant association between frequency of exercise and depression was also not observed in the present study which was opposite with the findings of previous studies (Hawker, 2012; Tyson et al., 2010). The differences might be partly explained by the different covariates adjusted for in the data analysis, no use of objective tool in measuring physical activity, lower physical activity compared to their counterparts in the developed countries, and age profile limited to 17 to 22 year old individuals in this study. In the present study, family income per month and educational level of parents were also nonsignificantly associated with depression. Currently, the association between family socio-demographic characteristics (primarily presented by family income situation and educational levels of parents) and depression among medical students is not established (Sidana et al., 2012; Sun et al., 2011) and further research is needed. Due to the limited number of male participants (13.4%) in this study, we were not able to explore gender differences in depth. Hence, more work is required to investigate the differences between male and female nursing students in regard to some of the associations observed in the present study. A potential limitation of this study is its cross-sectional design, which has made it difficult to make reference in regard to the causality of depression. For example, a study indicated that depression was an important cause of poor academic performance among college students (Hysenbegasi et al., 2005). A follow-up study in the future may be used to determine the causal relationship between depression and risk factors identified in the current study. Secondly, due to the nature of exclusively self-reported measures, the results of this study have to be cautiously interpreted. However, participants in this study were ensured confidentiality by using anonymous reports and were told that no sanctions were connected to the answers. The procedure can decrease the possibility of dishonesty. Thirdly, the results of this study were parts of the research, which examined the association on dietary pattern and depression among Chinese college students. As a result, some variables, for example physical activity and stress level reported in the present study, could have been collected differently with higher precision and accuracy. Future research is needed to further understand the association between depression and the risk factors stated in the present study. Finally, less number of male nursing students in the current study may have reduced the power to detect gender differences. However, the large sample size of nursing college students, adequate control for
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confounding factors and the use of valid scale to identify depressive symptoms among the college nursing students of the present study might have warranted the validity of the study. Conclusions Although much work remains to be done before one can determine the causality of depression among nursing students, the current study definitely provided valuable contribution to the literature. This study was able to identify risk factors, which were significantly related to depression among nursing students in China. This study also suggested several important practical implications for the health care profession or the authorities of medical college to consider suitable strategies at the familial, college and societal level to deal with the depression issue, so that the nursing students could be competent nurses with healthy mental status for the nursing work force in China. Contributors Authors Ying Xu and Yi Yang designed the study and wrote the protocol. Authors Juan Qi, Shaofeng Chen and Pide Zhang undertook the collection of data. Authors Ying Xu and Xinli Chi wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript. Conflicts of Interest/Disclosure Statement All authors have no personal or financial conflicts of interest to declare. Acknowledgments The project was funded by the Foundation of the Ministry of Education of China for Young Teachers [Grant no: 11YJCZH204]. The authors would like to thank all instructors and their assistants for their help during the course of the investigation, and also all of the operators who contributed to the study. References Ahmadi, J., Toobaee, S., Alishahi, M., 2004. Depression in nursing students. J. Clin. Nurs. 13 (1), 124. Aselton, P., 2012. Sources of stress and coping in American college students who have been diagnosed with depression. J. Child Adolesc. Psychiatr. Nurs. 25 (3), 119–123. Christensson, A., Vaez, M., Dickman, P.W., Runeson, B., 2011. Self-reported depression in first-year nursing students in relation to socio-demographic and educational factors: a nationwide cross-sectional study in Sweden. Soc. Psychiatry Psychiatr. Epidemiol. 46 (4), 299–310. Dyrbye, L.N., Thomas, M.R., Shanafelt, T.D., 2006. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad. Med. 81 (4), 354–373. Farabaugh, A., Bitran, S., Nyer, M., Holt, D.J., Pedrelli, P., Shyu, I., Hollon, S.D., Zisook, S., Baer, L., Busse, W., Petersen, T.J., Pender, M., Tucker, D.D., Fava, M., 2012. Depression and suicidal ideation in college students. Psychopathology 45 (4), 228–234. Furegato, A.R., Santos, J.L., Silva, E.C., 2008. Depression among nursing students associated to their self-esteem, health perception and interest in mental health. Rev. Lat. Am. Enfermagem. 16 (2), 198–204. Han, C.S., Oliffe, J.L., Ogrodniczuk, J.S., 2013. Suicide among East Asians in North America: a scoping review. J. Ment. Health 22 (4), 361–371. Harris, T.L., Molock, S.D., 2000. Cultural orientation, family cohesion, and family support in suicide ideation and depression among African American college students. Suicide Life Threat. Behav. 30 (4), 341–353. Harris, M.F., Penrose-Wall, J., 2001. Mental distress or disorder? Med. J. Aust. 175 (Suppl.), S6–S7. Hawker, C.L., 2012. Physical activity and mental well-being in student nurses. Nurse Educ. Today 32 (3), 325–331. Herman, S., Archambeau, O.G., Deliramich, A.N., Kim, B.S., Chiu, P.H., Frueh, B.C., 2011. Depressive symptoms and mental health treatment in an ethnoracially diverse college student sample. J. Am. Coll. Health 59 (8), 715–720. Hsieh, Y.H., Hsu, C.Y., Liu, C.Y., Huang, T.L., 2011. The levels of stress and depression among interns and clerks in three medical centers in Taiwan — a cross-sectional study. Chang Gung Med. J. 34 (3), 278–285.
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