Archives of Academic Emergency Medicine. 2019; 7 (1): e5 OR I G I N A L RE S E A RC H Prevalence of Depression and Personality Disorders in the Beginning and End of Emergency Medicine Residency Pro- gram; a Prospective Cross Sectional Study Farhad Rahmati1, Saeed Safari1, Behrooz Hashemi1, Alireza Baratloo2, Roozbeh Khosravi Rad1∗ 1. Emergency Medicine Department, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 2. Emergency Medicine Department, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran. Received: September 2018; Accepted: October 2018; Published online: 25 January 2019 Abstract: Introduction: Emergency medicine physicians are constantly under psychological trauma due to encountering critically ill patients, mortality, and violence, which can negatively affect their mental and physical health. The present study was performed with the aim of determining the rate of depression and personality disorders in first-year emergency medicine residents and comparing it with the time they reach the 3rd year. Methods: In the present prospective cross-sectional study, emergency medicine residents working in multiple teaching hos- pitals were included via census method and evaluated regarding the rate of depression and personality disorders using the standard MMPI-2 questionnaire upon admission to the program and graduation and their status re- garding the evaluated disorders were compared between the 2 phases of evaluation. Results: 99 residents with the mean age of 33.93 ± 5.92 years were evaluated. 85 (85.85%) rated their interest in their discipline as mod- erate to high. The rates of stress (p = 0.020), anxiety (p < 0.001), and hypomania (p = 0.015) had significantly increased during the 3 years and psychasthenia rate had decreased significantly during this time (p = 0.002). Changes in the prevalence of other disorders on the third year compared to the year of admission to emergency medicine program were not significant. Conclusion: Considering the results of the present study, it seems that paying more attention to mental problems and decreasing environmental stressors of medical residents, es- pecially emergency medicine residents, should be among the priorities of managers and policymakers of this discipline. Keywords: Depression; Anxiety; Stress, Psychological; Internship and Residency; Emergency Medicine Cite this article as: Rahmati F, Safari S, Hashemi B, Baratloo A, Khosravi Rad R. Prevalence of Depression and Personality Disorders in the Beginning and End of Emergency Medicine Residency Program; a Prospective Cross Sectional Study. Arch Acad Emerg Med. 2019; 7(1): e5. 1. Introduction A considerable part of each individual’s life is spent in the workplace. Environmental factors such as noise, crowding, improper light and sound, human factors like conflict with other individuals, and organizational factors such as work density, improper policy making, injustice and many other factors are among the stressors of workplace. If an individual is not able to effectively cope with these mental pressures, numerous physical, mental, and behavioral side effects will manifest and this will bring about decrease in effectiveness and job dissatisfaction (1). The rate of anxiety in those work- ∗Corresponding Author: Roozbeh Khosravi Rad; Emergency Depart- ment, Tajrish Square, Shahrdari Avenue, Tehran, Iran. Email: khosravi- rad@yahoo.com Tel: 00989122065315 ing in the field of healthcare is higher than the general pop- ulation and this is related to long night shifts, low sleeping hours, and high and exhausting workload (2). The emergency department is among the hospital environments with a high tension. Physicians and other emergency staff are constantly under psychological trauma due to encountering critically ill patients, mortality, and violence, which can negatively affect their mental and physical health (3). Emergency physicians experience a high degree of job burnout throughout their ca- reer, this rate has been estimated to be about 49% to 65% in emergency medicine residents (4-6). Studies have shown that medical residents experience higher degrees of depres- sion compared to other students (7-11). These facts have received attention from graduate accreditation association and a movement has been initiated for improving physicians’ mental health (12). This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem F. Rahmati et al. 2 Evaluating the health condition of medicine students and evaluating the effects of work environment on their psycho- logical balance seems necessary for better planning and im- proving the conditions by reducing preventable stressors. Therefore, the present study has been performed with the aim of evaluating the rate of depression and personality dis- orders in first-year emergency medicine residents and com- paring it with the time they reach the 3rd year. 2. Methods 2.1. Study design and setting In the present prospective cross-sectional study, all of the first-year emergency medicine residents of Shahid Beheshti University of Medical Sciences, admitted in 2014-2015, were evaluated. The questionnaires used were filled out after ob- taining informed consent and by keeping data of the partic- ipants completely confidential, once when they entered the program (first year) and once at the time of graduation (third year). The study was approved by the ethics committee of Shahid Beheshti University of Medical Sciences. 2.2. Participants Sampling was done using census method and all of the first- year residents, working in teaching hospitals affiliated with the mentioned university, were included without any age or sex limitation. Not giving consent for participation in the study or dropping out of the program and not filling the ques- tionnaire on the third year were exclusion criteria. 2.3. Data gathering The tools used for gathering data in this study were baseline characteristics questionnaire and 71-question MMPI2 ques- tionnaire for evaluating the rate of depression and person- ality disorders. Minnesota Multiphasic Personality Inven- tory (MMPI) is a standard questionnaire for recalling a broad range of self-described characteristics and scoring them, which gives a quantitative index of the individual’s emotional and their viewpoint on participating in the test (13). All first- year residents filled out the questionnaires in the first phase of the study and their data were recorded. Then 2 years later and in the second phase of the study, the same residents, who had become third-year residents then, filled out the ques- tionnaires again. Finally, the data gathered in the first and third year were compared. In addition, important happen- ings affecting mental health (such as getting married, having babies, losing dear ones, acute problem in the family, acute disease for the residents themselves,. . . ) that had happened during the 2 years (between the 2 phases of the study) were also recorded to eliminate their confounding effect. The per- son in charge of data gathering was an emergency medicine resident that personally gathered the data on the first and Table 1: Baseline characteristics of the studied residents Variable Frequency (%) Sex Male 43 (43.4) Female 56 (56.6) Age (year) 25 – 34.9 59 (59.60) 35 – 44.9 34 (34.34) > 45 6 (6.06) Marital status Married 50 (50.50) Single 49 (49.50) Household breadwinner Yes 29 (29.30) No 70 (70.70) History of consuming tranquilizers Yes 24 (24.24) No 75 (75.76) Smoking Yes 22 (22.22) No 77 (77.78) Family history of psychiatric disorders Yes 23 (23.23) No 76 (76.77) Sports activities Low 49 (49.50) Moderate 42 (42.42) High 8 (8.08) Interest in emergency medicine Low 14 (14.15) Moderate 41 (41.41) High 44 (44.44) Monthly outcome (US dollars) 500 – 1000 37 (37.38) 1000 – 1500 42 (42.42) > 1500 20 (20.20) third year. 2.4. Statistical Analysis Data were analyzed using SPSS software, version 18. To de- scribe data, mean and standard deviation or frequency and percentage of the variables were used. Before-after test was applied for comparing the condition of personality assess- ment indices on the first and third year. P<0.05 was consid- ered as level of significance. 3. Results 99 residents with the mean age of 33.93 ± 5.92 (26 – 55) years were evaluated (56.6% female). Table 1 has depicted the baseline characteristics of the studied residents. 85 (85.85%) residents rated their interest in their discipline as moderate to high and only 20 (20.20%) had an income more than 15 million Rials (1500 US dollars) a month. Table 2 has com- pared the prevalence of depression and other personality dis- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 3 Archives of Academic Emergency Medicine. 2019; 7 (1): e5 Table 2: Comparing the prevalence of various disorders among the studied residents in their first and third year of emergency medicine residency training Disorder No Mild Moderate severe Very severe P Depression First year 11 (11.1) 34 (34.3) 42 (42.4) 12 (12.1) 0 (0.0) 0.076 Third year 25 (25.3) 27 (27.3) 38 (38.4) 9 (9.1) 0 (0.0) Anxiety First year 29 (29.3) 33 (33.3) 28 (28.3) 6 (6.1) 3 (3.0) <0.001 Third year 14 (14.1) 19 (19.2) 39 (39.4) 22 (22.2) 5 (5.0) Stress First year 29 (29.3) 28 (28.3) 27 (27.3) 8 (8.1) 7 (7.1) 0.020 Third year 14 (14.1) 21 (21.2) 36 (36.4) 17 (17.2) 11 (11.1) Hypochondriasis First year 6 (6.1) 24 (24.2) 39 (39.4) 28 (28.3) 2 (2.0) 0.074 Third year 3 (3.0) 14 (14.1) 45 (45.5) 28 (28.3) 9 (9.1) Hysteria First year 13 (13.1) 24 (24.2) 37 (37.4) 24 (24.2) 1 (1.0) 0.113 Third year 6 (6.1) 39 (39.4) 29 (29.3) 23 (23.2) 2 (2.0) Psychasthenia First year 25 (25.3) 31 (31.3) 22 (22.2) 13 (13.1) 8 (8.1) 0.002 Third year 24 (24.2) 39 (39.4) 33 (33.3) 3 (3.0) 0 (0.0) Paranoia First year 21 (21.2) 43 (43.4) 16 (16.2) 17 (17.2) 2 (2.0) 0.079 Third year 7 (7.1) 48 (48.5) 20 (20.2) 22 (22.2) 2 (2.0) Schizophrenia First year 27 (27.3) 39 (39.4) 20 (20.2) 13 (13.1) 0 (0.0) 0.316 Third year 18 (18.2) 37 (37.4) 25 (25.3) 19 (19.2) 0 (0.0) Hypomania First year 30 (30.3) 49 (49.5) 18 (18.2) 2 (2.0) 0 (0.0) 0.015 Third year 13 (13.1) 58 (58.6) 21 (21.2) 7 (7.1) 0 (0.0) orders at the time the mentioned residents were enrolled in the emergency medicine program with their third year (the time of graduation). Based on the comparison, stress (p = 0.020), anxiety (p < 0.001), and hypomania (p = 0.015) had significantly increased during the 3 years and psychasthenia rate had decreased significantly during this time (p = 0.002). Changes in the prevalence of other disorders on the third year compared to the year of admission to emergency medicine program were not significant. 4. Discussion Based on the results of the present study, the rate of stress, anxiety and hypomania in the third year emergency medicine residents had significantly increased compared to the time they were first admitted to the residency program and severity of psychasthenia had decreased. Changes in the rate of other disorders on the third year compared to the year of admission to emergency medicine program were not sig- nificant. Considering the nature of their job, physicians and healthcare team members are more exposed to stress and anxiety compared to other people in the society (2). There- fore, paying attention to this matter in this group of peo- ple is very important. Studies that have been carried out in this regard have reported contradicting results regarding the rate of stress that medical staff members bear; some have re- ported high rates of stress in surgeons (14) and emergency physicians (15), and in some other studies no significant dif- ference was found regarding stress rate in emergency physi- cians (16). In another study, results showed that the rate of cortisol measured in residents was not related to the year of residency program they were in (17). However, in another study, the level of stress among professors of medicine had a significant increase after a few years passing (18). This finding shows that increase in cortisol production following stress does not significantly drop with gaining experience (17). An increase in the rate of anxiety following increase in the years of residency in residents was another finding of the present study, which is in line with the study by Buddeberg- Fischer et al. (19). Cabrera et al. (2018) found that emergency medicine residents experience many times more stress and anxiety compared to the general population and this increase in anxiety directly correlates with the increase in their dura- tion of stay and shifts in the emergency department. In this study, no sex difference was observed between the residents regarding anxiety rate (17). Overall, it should be noted that in addition to the problems that stress, anxiety, and depres- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem F. Rahmati et al. 4 sion as factors of mental health cause for the resident during education, they also lead to interference with their profes- sional role and taking responsibility of the society’s health in the future. Therefore, it seems that prevention of stress, anx- iety and depression of residents and decreasing their mental pressure can play an important role in increasing their inter- est in working and protecting people’s health in acute and critical situations and cooperating with the group and feel- ing responsible. Considering the results of the present study, it seems that paying more attention to mental problems of medical residents, especially emergency medicine residents, should be among the priorities of managers and policymak- ers of this discipline. 5. Limitation One of the limitations of the present study is its small sam- ple size, which was also seen in previous studies (15, 20). Inability to control some confounding factors such as the menstrual cycle, and personal and family problems were also among the limitations of this study. Another important point is that a control group was not available for performing more comparisons. 6. Conclusion Based on the results of the present study, the rate of stress, anxiety, and hypomania in the third year emergency medicine residents had significantly increased compared to the time they were first admitted to the residency program and severity of psychasthenia had decreased. Changes in the rate of other disorders on the third year compared to the year of admission to emergency medicine program were not sig- nificant. 7. Appendix 7.1. Acknowledgements All the residents and teaching staff members of hospitals af- filiated with Shahid Beheshti University of medical sciences are thanked for their cooperation. 7.2. Author contribution All authors met the four criteria for authorship contribution based on recommendations of the International Committee of Medical Journal Editors. Authors ORCIDs Saeed Safari: 0000-0002-7407-1739 Behrooz Hashemi: 0000-0002-5077-8545 Alireza Baratloo: 0000-0002-4383-7738 7.3. Funding/Support None. 7.4. Conflict of interest None. References 1. Vaziri S, Mohammadi F, Mosaddegh R, Masoumi G, Noy- ani A, Bahadormanesh A. Prevalence and Causes of Job Burnout Syndrome among Emergency Medicine Resi- dents of Iran University of Medical Sciences. Iranian Journal of Emergency Medicine. 2016;5(10):1-6. 2. Pereira-Lima K, Loureiro SR. Burnout, anxiety, depres- sion, and social skills in medical residents. Psychol Health Med. 2015;20:353-62. 3. Vanyo L, Sorge R, Chen A, Lakoff D. Posttraumatic Stress Disorder in Emergency Medicine Residents. Annals of Emergency Medicine. 2017;70(6):898-903. 4. Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, et al. 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