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Coping with depressed mood among Chinese medical students in Hong Kong
Journa! -of_~ffectke Disorders, 24 (1992) 109- 116 0 1992 Elsevier Science Publishers B.V. All rights reserved 01650327/92/$05.00
109
JAD 00869
wi
avid W. Chan Department of Educational Psychology, The Chinese Urkersity of Hong Kong, Shatin, NT, Hong Kong
(Received 29 May 1991) (Revision received 15 October 1991) (Accepted 12 November 1991)
Depressed mood and coping activities were assessed in a sample of 95 undergraduate medical students using the Beck Depression Inventory and the Coping Strategies Scales. Problem-focused activities were commonly employed by students and were perceived as helpful although activities involving brooding over problems, perceived as less helpful, were also commonly employed. There were few sex differences in employment of specific activities. In terms of coping strategies, depressed students tended to avoid and deny problems and contain their emotions, and depressed females in particular were more passive. It is suggested that while depressed and nondepressed students equally employed apparently adaptive strategies such as problem-solving and cognitive restructuring, the effectiveness of these strategies could be undermined by depressed students’ brooding over problems and passivity.
Key worclfs: Depression; Coping activities; Coping strategies, Chinese medical students
troduction Depression has been recognized as a significant health problem for medical students in various stages of their medical training. Zoccolillo et
Address for correspondence: Dr. David W. Chan, Department of Educational Psychology, Faculty of Education, The Chinese University of Hong Kong, Shatin, NT, Hong Kong. * This study was supported in part by a research grant from the Hsin-Chong/Godfrey-Yeh Education Foundation of the Chinese University of Hong Kong.
al. (1986), for example, reported that the incidence: of major depression or probable major depression during the first 2 years of medical school was 12%. Clark and Zeldow (1988) also estimated similar rates from elevated self-reported scores on the Beck Depression Inventory (BDI) from medical students during their first 3 years. The disturbingly high rates of depression have led investigators to study medical students as a group more vulnerable to depressed mood (Clark and Zeldow, 1988; Clark et al., 1984; Firth, 1986; Valko and Clayton, 1975; Zoccolillo et al., 1986). While familial predisposition, previous
personality factors of medical students have all been implicated in past studies as factors contributing to the emergence of a depressive illness or high dysphoria scores (Zeldow et al., 1985, 1988; Zoccolillo et al., 1986), these factors are generally not readily modifiable, The assumption that depression is the consequence of the stress of medical training has also led to reevaluating the academic strain associated with medical school curricula and environments (Adsett, 1968; Huebner et al., 1981; Weinstein, 1983). Since the large amount of material to be mastered and the responsibility for patient care put limits on the amount of stress that can be reduced, the importance of providing better support resources and counseling services for students to cope with stress and depression is increasingly recognized (Adsett, 1968; Clark and Zeldow 1988; Lucas, 1976; Notman and Nadelson, 1973; Weinstein, 1983). The failure to cope with stressful situations through the use of cognitive or behavioral coping strategies has been suggested to contribute to depression in the general population (e.g., Beckham and Adams, 1984). Consequently, a variety of depression coping strategies has been investigated. They included, among others, activity and work, self-care and maintenance, pharmacological alternatives, help and comfort seeking (Rippere, 1977), and emotional and information support seeking (Coyne et al., 1981). Some sex differences in coping with depression have also been found. While men were more likely to cope by becoming involved in activities, women more often coped by talking with close friends and overeating (Funabiki et al., 1980). Women who developed new interpersonal relationships were also found to be more likely to get over their depression than those who did not (Doerfler and Richards. 1981). In line with these studies, it has been suggested that teaching coping skills may help relieve medical students who recognize the symptoms in themselves and become aware that effective coping strategies are available (FirthCozens, 1987). Thus the study of how medical students cope with their depressed mood may eventually lead to promoting positive changes from less adaptive to more adaptive coping strategies among medical students.
episodes
of depression, and premorbid
The medical schools in Hong Kong are widely believed to be highly stressful, and a notable proportion of Chinese medical students have reported depressed mood at one time or another during their medical training. A recent survey of 335 first to fourth year Hong Kong Chinese medical students to assess their depressed mood with the BDI indicated that 48% scored in the depressed range (BDI score of 10 or above) and 12% in the moderate to severe range (BDI score of 19 or above) (Chan, 1991). However, there have been few studies addressing how Chinese medical students in Hong Kong cope with their depressed mood. Thus, the present study was designed to investigate the activities and strategies employed by a sample of Hong Kong Chinese medical students to cope with their depressed mood. Specifically, it was concerned with: (1) identifying the common and effective coping activities of Chinese medical students; (2) examining the relationships between coping strategies and depressive symptom level; and (3) comparing the ceding activities and strategies of depressed and nondepressed students. In addition, sex differences on coping activities and strategies would also be explored. ethod Subjects md procedrrre
The subjects who participated voluntarily in the study were 95 first year undergraduate medical students (64 males and 38 females) at the Chinese IJniversity of Hong Kong. They were single and were between the ages of 18 and 29 (mean 19.62, SD 1.35). In small group sessions all 95 medical students responded anonymously to the 21-item Beck Depression Inventory (BDI) (Beck et al., 1979) and the Coping Strategies Scales (COSTS) (Beckham and Adams, 1984). Mensrrre of depressiort or dyspltoi-ia
The BDI was designed to assess 21 symptoms and attitudes which could be rated in terms of intensity. It reflects six of the nine criteria of the DSM-IIIR (American Psychiatric Association, 1987) for major depression well, two partially (sleep and appetite disturbance), and one not at
all (psychomotor retardation or agitation). The scale shows good -*alidity and reliability (Beck et al., 1988). It is recognized that high BDI scores alone are insufficient as indices of nosologic depression (Kendall et al., 1987), and the scale has bee.1 employed in this study p!s a measure of self-reported depressed mood. Measure of coping strategies The Coping Strategies Scales (COSTS) were designed to measure a wide range of adaptive and nonadaptive behaviors and thoughts that might occur in persons attempting to cope with feeling ‘depressed’ or ‘down’ (Beckham and Adams, 1984). The scales were designed to assess recent coping attempts in the past 2 weeks and also reflect whether a person felt better, worse, or the same after the specific coping behaviors which he or she endorsed were performed. The 142 activities or items can be scored into 10 scales reflecting 10 different coping strategies: Blame, Emotional Expression, Emotional Containment, Social Support/ Dependency, Religious Support, Philosophical/ Cognitive Restructuring, General
TABLE
Activity, Avoidance/ Denial, Problem-Solving, and Passivity. Good psychometric properties of the COSTS with depressed patients have been reported (Beckham and Adams, 1983). Results
The item responses of the 95 medical students on the BDI were aggregated to yield scores (range l-41) reflecting their degree of depressed mood or dysphoria (mean 11.92, SD 7.31). Sex differences on score distributions and mean BDI scores were nonsignificant (P > 0.05). Activities in coping with feeling depr ssed The item responses of 95 medical students to the COSTS were tabulated to indicate the depression coping activities of students. In general, the proportions of male and female students engaging in specific activities were roughly similar. Table 1 shows the list of activities emplcyed by students to deal with feeling depressed. Only the most frequently employed activities (by 85% or more of the students) and the least frequently
I
ACTIVITIES
EMPLOYED
BY MEDICAL
STUDENTS
TO COPE WITH FEELING
DEPRESSED
Proportion Mot-c cotwmtt
of students
crctilitic~s
I Tried accepting problems (4)
0.98
0.98
2 Took steps to overcome problems ( 11) 3 Read a Ic)t ( 1) 4 Decided lo accept problems ( 15) 5 Took steps to improve problems (89) 6 Thought about ways to overcome problems (56) 7 Thought about problems a lot (38) 8 Wont ovler problems in mind over and over (35) 9 Tried to find meaning in difficult situation (IO) IO Told self about similar problems in others (SC)) I1 Told self that problems are a small part of life (142) 12 Talked with friends and relatives about problems (3) 1.3Did something constructive (129) Lc~s wttmtwi crctii*itks 1 Drank alcohol or used drugs to reduce feeling dcpresscd 2 Did something wild, reckless, or illegal (23) 3 Became more sexually active ( I 10) 4 Cried before someone ( 122)
0.07 0.95 0.94 0.92 0.90 0.88 0.87 O.Xh 0.86 0.85 0.85
(2 1)
More common activities were those engaged in by 85% or more of the students: Numbers
01 = 951
in parentheses are item numbers.
0.11 0.14
0.17 0.20 less common ones were engaged in by 3~
or less.
112 TABLE 2 COPING
ACTlVlTIES
THAT TENDED
TO MAKE STUDENTS
FEEL BETTER
OR WORSE
Activities
Proportion
1 Took steps to overcome problems (11) 2 Decided to accept problems (15) 3 Took steps to improve problems (89) 4 Thought about ways to overcome problems (56) 5 Tried thinking positively and ignoring the negative (766 6 Told self that problems are a small part of life (142) 7 Talked to a friend about problems (44) 8 Asserted self and took positive action on problems (81) 9 Did something constructive (129) 10 Talked with friends and relatives about problems (3)
IVXofelt better 0.77 0.68 0.68 0.67 0.65 0.65 0.63 0.62 0.62 0.60
1 Worried about y&em a lot (47) 2 Was unusually emotional (8) 3 Went over problems in mind over and over (35) 4 Thought about problems a lot (38) 5 Hid feelings from others (7) 6 Blamed self for problems (27) 7 Felt angry but held it in (79) 8 Watched TV a lot (2) 9 Thought how one has brought problems on self (67) 10 Tried not to worry about problems ( 17)
Who fdt w0r.w 0.39 0.31 0.3 1 0.31 0.28 0.24 9.24 0.22 0.2: 0.20
(n = 95)
of students
Only activities which made 6C%- or more students felt better and activities which made 20 Sb or more students feel worse are shown. Numbers in parentheses are item numbers.
emp1oy.J activities (by 20% or less) are shown. The more common activities were problem-oriented, with some cognitive restructuring and other constructive activities not bearing directly on the In contrast, the less common activities were not problem-oriented and could be considered as less constructive. Table 2 lists the activities which tended to make students feel better or worse after doing them. In general, actively trying to resolve problems, seeking social support, and focusing on one’s strengths appeared to be behaviors and cognitions frequently reported to make students feel better, whereas passively thinking or worrying about problems, being unusually emotional, holding in feelings or blaming oneself appeared to be behaviors and cognitions rated as making ore feel worse. Coping strategies and deprcssiLlesymptom ler Tel
The 142 coping activities of the 95 students gene also scored on 10 scales of coping strategies.
The individual scales were relatively internally consistent (coefficiem a! ranging from 0.58 to 0.88), and correlated significantly with each other (I’ = 0.21, P < 0.05 to P = 0.78, P < 0.0001). Sex differences in the scores on the 10 scales for the students were all nonsignificant (P > 0.05), reflecting that male and ft=male students did not differ in employing specific coping strategies. To explore whether specific coping strategies were differentially predictive of depressive symptom level, multiple linear regression was perforrned using the 10 scales to predict the BDI scores. The results showed that the 10 coping strategies could significantly predict depressive symptom level (K’ -. 0.20, Fb 10,84)= 2.12, P < 0.05), but none of the predictors achieved statistical significance. When similar analyses were conducted separately for male and female students, the results for the total sample extended only to female students CR2 = 0.56, F( 10,20)= 2.54, P < C1.05),and the strategy of Passivity emerged as the only significant predictor (6( 1) = 2.3 1, P < 0.05).
113
Depressed LT. nondepressed students To explore whether relatively depressed and nondepressed students differed in engaging in specific activities and strategies, the sample of students was divided into two groups using the BDI score cutoff of l&/I9 as suggested by Chan (1993) who used the BDI with nonclinical and clinical populations in the Chinese setting. High BDI scorers were then compared with low BDI scorers as depressed and nondepressed groups. Multivariate analysis of variance was first performed for the 10 coping strategies, showing that depressed and nondepressed students did not differ significantly in the use of the set of 10 coping strategies. Considering individual coping strategies separately, univariate t-tests indicated that depressed students were more likely to use strategies of Emotional Containment (t(93) = - 2.47, P’< O.Ol), and Avoidance/ Denial (t(93) = - 2.00, P < 0.05) than nondepressed students. Similar analyses were also conducted separately for male and female students. While the multivariate test yielded no significant results, it was noteworthy that univariate t-tests indicated that depressed females were more likely than nondepressed females to use the strategy of Passivity (t(29) = - 2.91, P < 0.01). Although there were few significant differences between depressed and nondepressed students at the level of coping strategies, it was of
interest to explore possible differences at the level of specific coping activities. Table 3 presents the specific activities with significant differences between the two groups. The activity employed by a larger proportion of nondepressed students was one related to active problem-solving, whereas those activities employed by a larger proportion of depressed students were related to blaming, avoiding or denying problems, containing emotions, and passive responding. When the differences between depressed and nondepressed students were explored within each sex, the pattern of significant differences revealed that more depressed than nondepressed male students reported accepting the sick role, trying to act as if not feeling bad, and would resort to activities related to blaming, acting out, and using drug or alcohol. In contrast, significantly more depressed than nondepressed female students reported sleeping more than usual. However, these fine differences were only suggestive as the sample size of depressed students for each sex was very small. Discussion
The finding that a large proportion of Chinese medical students in Hong Kong scored in the BDI depressed range has raised concerns about the claims of widespread depressed mood among
TABLE 3 COPING
ACTIVITIES
OF NONDEPRESSED
AND DEPRElSSED
Activities
MEDICAL Proportion BDI I 18 (12= 80)
1 Hated someone for causing problems (91 2 Expressed anger at spouse or someone close ( 191 3 Drank alcohol or used drug to reduce feeling depressed (21) 4 Did something wild, reckless or illegal 623) 5 Blamed others for problems (251 6 Accepted self as a sick person (971 7 Kept feeling bottled up (113) 8 Tried acting as if not feeling bad (139) 9 Asserted self and took positive action on problems (81)
0.38 0.34
0.M 0.09 0.29 0.23 0.48 0.34 0.86
STUDENTS
(n = 95) X2
of students BDI > I8 (I2 =
0.73 0.73 0.33 0.40 0.60 0.67 0.80 0.67 0.60
15)
5.23 6.68 7.17 7.97 4.21 982
* ** **: *** * ***
4.13 * 4.46 * 4.27 *
Only activities with significant differences are shown. Activities 1-S were employed by more depressed students and activity 9 by more nondepressed students. Numbers in parentheses are item numbers. Yates’ correction has been applied to all chi-squares. * P < 0.05; * * P < 0.01; * * * P < 0.00s.
Chinese medical students Khan, 1991). Apart from attempts to foster learning in a less stressful environment, it has been deemed desirable to help students cope with their depressed mood through acquiring and using more effective and adaptive coping strategies. Thus, the present study was designed with the purpose of clarifying and elucidating the nature and type of activities of Chinese medical students in coping with depressed mood. The general findings demonstrated that the common activities were those which were generally problem-focused, including seeking support from friends and other constructive activities, although they might also include rumination and preoccupation with problems without taking steps toward solving them. Nonetheless. taking act ion on solving problems and seeking support were perceived as some of the most helpful activities whereas poor emotional regulation, blaming oneself and brooding over problems were perceived as least helpful. Thus, it may prove helpful to promote adaptive problem-oriented coping activities in students when they feel depressed. At the level of coping strategies, the present findings also bear indirectly on the notion that depressed individuals are more likely to employ less adaptive coping strategies irt coping with depression. As expected, depressed students were more likely to USC’strategies of emotional containment and avoidance/denial. When such differences were t::plored within each sex, depressed females were characterized by their strat-
egy of passivity, which was also predictive of the depressive symptom level of female students. In cant rast. depressed males and nondepressed males did not differ significantly in their use of coping strategies, which were also not predictive of their depressive symptom level. The finding that passivity predicted depressive symptom level in females but not in males merits more attention in future studies. Caution, however, should be exercised in interpreting these sex differences as the sample of female students was very small. Less expected and somewhat at variance with the view of nonadaptive coping and depression was the lack of difference in the USCof apparently adaptive strategies of problem-solving and cognitive restructuring. The lack of difference might
indicate that both nondepressed and depressed individuals attempted to employ adaptive strategies but nondepressed individuals used these strategies more actively and therefore more effectively. Thus, both groups might use cognitive restructuring but only the nondepressed individuals would believe in the positive self-statements and the depressed individuals would accept the unhappy situation with a sense of resignation. Both groups might also use problem-solving, but the depressed individuals would feel less certain and more indecisive in taking action (Coyne et al., 15X31),and would rather wait to see whether problems would resolve by themselves. Thus, the use of problem-solving and cognitive restructuring could be easily undermined by brooding over problems and passivity. Although the present findings did not substantiatc significant sex differences in the use of coping strategies, the contrast between depressed and nondcpressed individuals separately in male and female students revealed indirectly certain possibly subtle differences in their coping activities. These sex differences were at best suggestive as the subsamples were very small. Nonetheless, the finding that depressed males tended to contain their emotions was consistent with the general view that it is less socially acceptable for Chinese men to express depression especially when the depressed mood is perceived to be caused by oncsclf not being able to meet life’s challenges. In contrast, females students’ expression of depression may be more socially acceptable, but depressed females would passively wait for problems to resolve by themselves. These subtle differences in the pattern of coping activities may have implications in the help-seeking behaviors of male and female students. Male students may be reluctant to seek professional help for their depressed mood because of social undesirability, while female students may keep procrastinating because of passivity. Some of the major limitations in the present study lit in its cross-sectional design and analyses, its reliance on self-report measures of coping, and the omission of person and contextual variables affecting coping. The cross-sectional design made it impossible to establish the direction of causality. While passivity was found to be one of
the coping strategies which predicted depressive symptom level among female students and differentiated depressed from nondepressed females, the question still remained whether female students who tended to use passive strategies became more depressed, or whether depressed females were more likely to use passive strategies and maintained their depressed mood. The alternative interpretation of an association between passivity and depression by d third factor such as personal control, or even the method of self-report, has not been ruled out in this study. Thus, depressed individuals may respond to the coping questionnaire in a biased way as they may not recall having engaged in any active strategies regardless of whether or not they have actually done so. Further, the assessment of contextual variables such as social support was omitted in this study. The sources and availability of social support may have important implications for the use of coping strategies as depressed persons have been reported to alienate needed sources of social support (Coyne, 1976). These issues, however, can only be resolved with longitudinal designs, the employment of behavioral measures and judgement data in the assessment of coping behaviors and cognitions, and the inclusion of person and situation factors as determinants of coping in future studies. The present findings also have implications for promoting adaptive coping activities and strategies among medical students in their stressful medical school environment. It appears that medical students genera!ly employed problem-focused activities, and depressed mood was associated with nonadaptive strategies of emotion containment and avoidance/denial, and possibly with the ineffective use of adaptive strategies. Thus, to of ensure effcctivc and active implementation adaptive strategies, coping skills aimed at active problem-solving, appropriate emotional regulation, and seeking out and maintaining social support should be systematically taught rather than being left solely to the students to be haphazardly acquired. Although this study was designed to focus on medical students, guidelines emerging from these findings are perhaps equally applicable to Chinese university undergraduates. While the generalizability of these results was limited by
thz questionable representativeness of this sample of medical students as they were relatively young, single, well-educated, and likely to be influenced by Western health thoughts, this sample of first year students was new to the medical school and they were not different from other university freshmen in their involvement in the health profession. Nonetheless, the need for replication in future studies with medical and nonmedical students and other nonselected or selected populations should be emphasized. References Adsett, C.A. (1968) Psychological hea!th of medical students in relation to the medical education process. J. Med. Educ. 43. 728-734. American Psychiatric Association (1987) Diagnostic and Statistical Manual of Mental Disorder, 3rd edn., revised. American Psychiatric Press, Washington, DC. Beck, A.T., Rush, A.J., Shaw. B.F and Emery, G. (1979) Cognitive Therapy of Depression. Guilford, New York, NY. Beck. A.T.. Steer, R.A. and Garbin, M.G. (1988) Psychometric properties of the Beck Depression Inventory: twentyfive years of evaluation. Clin. Psychol. Rev. 8. 77-100. Beckham, E.E. and Adams, R.L. (1984) Coping behavior in depression: report on a new scale. Behav. Res. Ther. 22, 71-75. Ghan, D.W. ( I991 ) Depressive symptoms and depressed mood among Chinese medical students in Hong Kong. Compr. Psyc hiatty 32. I - I 1. Chan. D.W. (1992) The Beck Depression Inventory: what difference does the Chinese version make? Psychol. Assess. J. Consult. Clin. Psychol. ‘in press). Clark, D.C. and Zeldow. P.B. (1988) Vicissitudes of depressed mood during four years of medical School. J. Am. Med. Ass. 260, 252 i-2528. Clark, D.C.. Salazar-Grueso, E., Grabler, P. and Fawcett, 5. (1984) Predictors of depression during the first six months of internship. Am. J. Psychiatry 141, 1095-1098. Coyne. J.C. (1976) Toward an interactional description of depression. Psychir;try 39, 2X-40. Coyne. J.C.. Alwin, C. and Lazarus, R.S. (1981) Depression and coping in stressful episodes. J. Abnorm. Psychol. 90, 439-447. Doerfler. L.A. and Richards, C.S. (1981) Self-initiated attempts to cope with depression. Cogn. Ther. Res. 5. 367371. Firth, J.A. (1986) Levels and sources of stress in medical students. Br. Med. J. 292. 1177-l 180. Firth-Cozens, J. (1987) The stresses of medical trainmg. In: R. Payne and J. Firth-Cozens (Eds.), Stress in Health Professionals. Wiley, Chichester. Funabiki, D.. Bologna, N.C., Pepping, M. and FitzGerald,
116 K.C. (1380) Revisiting sex differences in the expression depression. J. Abnorm. Psychol. 89, 194-202.
of
Huebner. L.A.. Royer, J.A. and Morrel. J. (19811 The assessment and remediation of dysfunctional strr;s in medical students. J. Med. Educ. 56,547-5X Kendall, P.C., Hollon, S.D., Beck, A.T., Hammer, C.L. and
Ingram, R.E. (1987) Issues and recommendations regarding use of the Beck Depression Inventory. Cogn. Ther. Res. 11, 289-299. Lucas, C.J. (1970) Psychological problems of students. Br. Med. J. 2, 1431-1433. Notman, M.T. and Nadelson, CC. (1973) Medicine: a career conflict for women. Am. J. Psychiatry 130. 1123-1127. Rippere. V. (19771 Some cognitive dimensions of antidepressive behavior. Behav. Res. Ther. 15. 185-191.
Valko. R. and Clayton, P. (1975) Depression in the internship. Dis. Nerv. System 36, 26-29. Weinstein, H-M. (1983) A committee on well-being of medical students and house staff. J. Med. Educ. 58, 373-381. Zeldow, P.B., Daugherty, S.R. and Clark, DC. (1985) Masculinity, femininity, type A behavior, and psychosocial adjustment in medical students. J. Person. Sot. Psychol. 48, 48 l-492. Zeldow, P.B., Daugherty, S.R. and McAdams, D.P. (1988) Intimacy, power and psychological well-being in medical students. J. Nerv. Ment. Dis. 176, 182-187. Zoccolillo. M., Murphy, G.E. and Wetzel, R.D. (1986) Depression among medical students. 9. Affect. Disord. 11, 91-96.
109
JAD 00869
wi
avid W. Chan Department of Educational Psychology, The Chinese Urkersity of Hong Kong, Shatin, NT, Hong Kong
(Received 29 May 1991) (Revision received 15 October 1991) (Accepted 12 November 1991)
Depressed mood and coping activities were assessed in a sample of 95 undergraduate medical students using the Beck Depression Inventory and the Coping Strategies Scales. Problem-focused activities were commonly employed by students and were perceived as helpful although activities involving brooding over problems, perceived as less helpful, were also commonly employed. There were few sex differences in employment of specific activities. In terms of coping strategies, depressed students tended to avoid and deny problems and contain their emotions, and depressed females in particular were more passive. It is suggested that while depressed and nondepressed students equally employed apparently adaptive strategies such as problem-solving and cognitive restructuring, the effectiveness of these strategies could be undermined by depressed students’ brooding over problems and passivity.
Key worclfs: Depression; Coping activities; Coping strategies, Chinese medical students
troduction Depression has been recognized as a significant health problem for medical students in various stages of their medical training. Zoccolillo et
Address for correspondence: Dr. David W. Chan, Department of Educational Psychology, Faculty of Education, The Chinese University of Hong Kong, Shatin, NT, Hong Kong. * This study was supported in part by a research grant from the Hsin-Chong/Godfrey-Yeh Education Foundation of the Chinese University of Hong Kong.
al. (1986), for example, reported that the incidence: of major depression or probable major depression during the first 2 years of medical school was 12%. Clark and Zeldow (1988) also estimated similar rates from elevated self-reported scores on the Beck Depression Inventory (BDI) from medical students during their first 3 years. The disturbingly high rates of depression have led investigators to study medical students as a group more vulnerable to depressed mood (Clark and Zeldow, 1988; Clark et al., 1984; Firth, 1986; Valko and Clayton, 1975; Zoccolillo et al., 1986). While familial predisposition, previous
personality factors of medical students have all been implicated in past studies as factors contributing to the emergence of a depressive illness or high dysphoria scores (Zeldow et al., 1985, 1988; Zoccolillo et al., 1986), these factors are generally not readily modifiable, The assumption that depression is the consequence of the stress of medical training has also led to reevaluating the academic strain associated with medical school curricula and environments (Adsett, 1968; Huebner et al., 1981; Weinstein, 1983). Since the large amount of material to be mastered and the responsibility for patient care put limits on the amount of stress that can be reduced, the importance of providing better support resources and counseling services for students to cope with stress and depression is increasingly recognized (Adsett, 1968; Clark and Zeldow 1988; Lucas, 1976; Notman and Nadelson, 1973; Weinstein, 1983). The failure to cope with stressful situations through the use of cognitive or behavioral coping strategies has been suggested to contribute to depression in the general population (e.g., Beckham and Adams, 1984). Consequently, a variety of depression coping strategies has been investigated. They included, among others, activity and work, self-care and maintenance, pharmacological alternatives, help and comfort seeking (Rippere, 1977), and emotional and information support seeking (Coyne et al., 1981). Some sex differences in coping with depression have also been found. While men were more likely to cope by becoming involved in activities, women more often coped by talking with close friends and overeating (Funabiki et al., 1980). Women who developed new interpersonal relationships were also found to be more likely to get over their depression than those who did not (Doerfler and Richards. 1981). In line with these studies, it has been suggested that teaching coping skills may help relieve medical students who recognize the symptoms in themselves and become aware that effective coping strategies are available (FirthCozens, 1987). Thus the study of how medical students cope with their depressed mood may eventually lead to promoting positive changes from less adaptive to more adaptive coping strategies among medical students.
episodes
of depression, and premorbid
The medical schools in Hong Kong are widely believed to be highly stressful, and a notable proportion of Chinese medical students have reported depressed mood at one time or another during their medical training. A recent survey of 335 first to fourth year Hong Kong Chinese medical students to assess their depressed mood with the BDI indicated that 48% scored in the depressed range (BDI score of 10 or above) and 12% in the moderate to severe range (BDI score of 19 or above) (Chan, 1991). However, there have been few studies addressing how Chinese medical students in Hong Kong cope with their depressed mood. Thus, the present study was designed to investigate the activities and strategies employed by a sample of Hong Kong Chinese medical students to cope with their depressed mood. Specifically, it was concerned with: (1) identifying the common and effective coping activities of Chinese medical students; (2) examining the relationships between coping strategies and depressive symptom level; and (3) comparing the ceding activities and strategies of depressed and nondepressed students. In addition, sex differences on coping activities and strategies would also be explored. ethod Subjects md procedrrre
The subjects who participated voluntarily in the study were 95 first year undergraduate medical students (64 males and 38 females) at the Chinese IJniversity of Hong Kong. They were single and were between the ages of 18 and 29 (mean 19.62, SD 1.35). In small group sessions all 95 medical students responded anonymously to the 21-item Beck Depression Inventory (BDI) (Beck et al., 1979) and the Coping Strategies Scales (COSTS) (Beckham and Adams, 1984). Mensrrre of depressiort or dyspltoi-ia
The BDI was designed to assess 21 symptoms and attitudes which could be rated in terms of intensity. It reflects six of the nine criteria of the DSM-IIIR (American Psychiatric Association, 1987) for major depression well, two partially (sleep and appetite disturbance), and one not at
all (psychomotor retardation or agitation). The scale shows good -*alidity and reliability (Beck et al., 1988). It is recognized that high BDI scores alone are insufficient as indices of nosologic depression (Kendall et al., 1987), and the scale has bee.1 employed in this study p!s a measure of self-reported depressed mood. Measure of coping strategies The Coping Strategies Scales (COSTS) were designed to measure a wide range of adaptive and nonadaptive behaviors and thoughts that might occur in persons attempting to cope with feeling ‘depressed’ or ‘down’ (Beckham and Adams, 1984). The scales were designed to assess recent coping attempts in the past 2 weeks and also reflect whether a person felt better, worse, or the same after the specific coping behaviors which he or she endorsed were performed. The 142 activities or items can be scored into 10 scales reflecting 10 different coping strategies: Blame, Emotional Expression, Emotional Containment, Social Support/ Dependency, Religious Support, Philosophical/ Cognitive Restructuring, General
TABLE
Activity, Avoidance/ Denial, Problem-Solving, and Passivity. Good psychometric properties of the COSTS with depressed patients have been reported (Beckham and Adams, 1983). Results
The item responses of the 95 medical students on the BDI were aggregated to yield scores (range l-41) reflecting their degree of depressed mood or dysphoria (mean 11.92, SD 7.31). Sex differences on score distributions and mean BDI scores were nonsignificant (P > 0.05). Activities in coping with feeling depr ssed The item responses of 95 medical students to the COSTS were tabulated to indicate the depression coping activities of students. In general, the proportions of male and female students engaging in specific activities were roughly similar. Table 1 shows the list of activities emplcyed by students to deal with feeling depressed. Only the most frequently employed activities (by 85% or more of the students) and the least frequently
I
ACTIVITIES
EMPLOYED
BY MEDICAL
STUDENTS
TO COPE WITH FEELING
DEPRESSED
Proportion Mot-c cotwmtt
of students
crctilitic~s
I Tried accepting problems (4)
0.98
0.98
2 Took steps to overcome problems ( 11) 3 Read a Ic)t ( 1) 4 Decided lo accept problems ( 15) 5 Took steps to improve problems (89) 6 Thought about ways to overcome problems (56) 7 Thought about problems a lot (38) 8 Wont ovler problems in mind over and over (35) 9 Tried to find meaning in difficult situation (IO) IO Told self about similar problems in others (SC)) I1 Told self that problems are a small part of life (142) 12 Talked with friends and relatives about problems (3) 1.3Did something constructive (129) Lc~s wttmtwi crctii*itks 1 Drank alcohol or used drugs to reduce feeling dcpresscd 2 Did something wild, reckless, or illegal (23) 3 Became more sexually active ( I 10) 4 Cried before someone ( 122)
0.07 0.95 0.94 0.92 0.90 0.88 0.87 O.Xh 0.86 0.85 0.85
(2 1)
More common activities were those engaged in by 85% or more of the students: Numbers
01 = 951
in parentheses are item numbers.
0.11 0.14
0.17 0.20 less common ones were engaged in by 3~
or less.
112 TABLE 2 COPING
ACTlVlTIES
THAT TENDED
TO MAKE STUDENTS
FEEL BETTER
OR WORSE
Activities
Proportion
1 Took steps to overcome problems (11) 2 Decided to accept problems (15) 3 Took steps to improve problems (89) 4 Thought about ways to overcome problems (56) 5 Tried thinking positively and ignoring the negative (766 6 Told self that problems are a small part of life (142) 7 Talked to a friend about problems (44) 8 Asserted self and took positive action on problems (81) 9 Did something constructive (129) 10 Talked with friends and relatives about problems (3)
IVXofelt better 0.77 0.68 0.68 0.67 0.65 0.65 0.63 0.62 0.62 0.60
1 Worried about y&em a lot (47) 2 Was unusually emotional (8) 3 Went over problems in mind over and over (35) 4 Thought about problems a lot (38) 5 Hid feelings from others (7) 6 Blamed self for problems (27) 7 Felt angry but held it in (79) 8 Watched TV a lot (2) 9 Thought how one has brought problems on self (67) 10 Tried not to worry about problems ( 17)
Who fdt w0r.w 0.39 0.31 0.3 1 0.31 0.28 0.24 9.24 0.22 0.2: 0.20
(n = 95)
of students
Only activities which made 6C%- or more students felt better and activities which made 20 Sb or more students feel worse are shown. Numbers in parentheses are item numbers.
emp1oy.J activities (by 20% or less) are shown. The more common activities were problem-oriented, with some cognitive restructuring and other constructive activities not bearing directly on the In contrast, the less common activities were not problem-oriented and could be considered as less constructive. Table 2 lists the activities which tended to make students feel better or worse after doing them. In general, actively trying to resolve problems, seeking social support, and focusing on one’s strengths appeared to be behaviors and cognitions frequently reported to make students feel better, whereas passively thinking or worrying about problems, being unusually emotional, holding in feelings or blaming oneself appeared to be behaviors and cognitions rated as making ore feel worse. Coping strategies and deprcssiLlesymptom ler Tel
The 142 coping activities of the 95 students gene also scored on 10 scales of coping strategies.
The individual scales were relatively internally consistent (coefficiem a! ranging from 0.58 to 0.88), and correlated significantly with each other (I’ = 0.21, P < 0.05 to P = 0.78, P < 0.0001). Sex differences in the scores on the 10 scales for the students were all nonsignificant (P > 0.05), reflecting that male and ft=male students did not differ in employing specific coping strategies. To explore whether specific coping strategies were differentially predictive of depressive symptom level, multiple linear regression was perforrned using the 10 scales to predict the BDI scores. The results showed that the 10 coping strategies could significantly predict depressive symptom level (K’ -. 0.20, Fb 10,84)= 2.12, P < 0.05), but none of the predictors achieved statistical significance. When similar analyses were conducted separately for male and female students, the results for the total sample extended only to female students CR2 = 0.56, F( 10,20)= 2.54, P < C1.05),and the strategy of Passivity emerged as the only significant predictor (6( 1) = 2.3 1, P < 0.05).
113
Depressed LT. nondepressed students To explore whether relatively depressed and nondepressed students differed in engaging in specific activities and strategies, the sample of students was divided into two groups using the BDI score cutoff of l&/I9 as suggested by Chan (1993) who used the BDI with nonclinical and clinical populations in the Chinese setting. High BDI scorers were then compared with low BDI scorers as depressed and nondepressed groups. Multivariate analysis of variance was first performed for the 10 coping strategies, showing that depressed and nondepressed students did not differ significantly in the use of the set of 10 coping strategies. Considering individual coping strategies separately, univariate t-tests indicated that depressed students were more likely to use strategies of Emotional Containment (t(93) = - 2.47, P’< O.Ol), and Avoidance/ Denial (t(93) = - 2.00, P < 0.05) than nondepressed students. Similar analyses were also conducted separately for male and female students. While the multivariate test yielded no significant results, it was noteworthy that univariate t-tests indicated that depressed females were more likely than nondepressed females to use the strategy of Passivity (t(29) = - 2.91, P < 0.01). Although there were few significant differences between depressed and nondepressed students at the level of coping strategies, it was of
interest to explore possible differences at the level of specific coping activities. Table 3 presents the specific activities with significant differences between the two groups. The activity employed by a larger proportion of nondepressed students was one related to active problem-solving, whereas those activities employed by a larger proportion of depressed students were related to blaming, avoiding or denying problems, containing emotions, and passive responding. When the differences between depressed and nondepressed students were explored within each sex, the pattern of significant differences revealed that more depressed than nondepressed male students reported accepting the sick role, trying to act as if not feeling bad, and would resort to activities related to blaming, acting out, and using drug or alcohol. In contrast, significantly more depressed than nondepressed female students reported sleeping more than usual. However, these fine differences were only suggestive as the sample size of depressed students for each sex was very small. Discussion
The finding that a large proportion of Chinese medical students in Hong Kong scored in the BDI depressed range has raised concerns about the claims of widespread depressed mood among
TABLE 3 COPING
ACTIVITIES
OF NONDEPRESSED
AND DEPRElSSED
Activities
MEDICAL Proportion BDI I 18 (12= 80)
1 Hated someone for causing problems (91 2 Expressed anger at spouse or someone close ( 191 3 Drank alcohol or used drug to reduce feeling depressed (21) 4 Did something wild, reckless or illegal 623) 5 Blamed others for problems (251 6 Accepted self as a sick person (971 7 Kept feeling bottled up (113) 8 Tried acting as if not feeling bad (139) 9 Asserted self and took positive action on problems (81)
0.38 0.34
0.M 0.09 0.29 0.23 0.48 0.34 0.86
STUDENTS
(n = 95) X2
of students BDI > I8 (I2 =
0.73 0.73 0.33 0.40 0.60 0.67 0.80 0.67 0.60
15)
5.23 6.68 7.17 7.97 4.21 982
* ** **: *** * ***
4.13 * 4.46 * 4.27 *
Only activities with significant differences are shown. Activities 1-S were employed by more depressed students and activity 9 by more nondepressed students. Numbers in parentheses are item numbers. Yates’ correction has been applied to all chi-squares. * P < 0.05; * * P < 0.01; * * * P < 0.00s.
Chinese medical students Khan, 1991). Apart from attempts to foster learning in a less stressful environment, it has been deemed desirable to help students cope with their depressed mood through acquiring and using more effective and adaptive coping strategies. Thus, the present study was designed with the purpose of clarifying and elucidating the nature and type of activities of Chinese medical students in coping with depressed mood. The general findings demonstrated that the common activities were those which were generally problem-focused, including seeking support from friends and other constructive activities, although they might also include rumination and preoccupation with problems without taking steps toward solving them. Nonetheless. taking act ion on solving problems and seeking support were perceived as some of the most helpful activities whereas poor emotional regulation, blaming oneself and brooding over problems were perceived as least helpful. Thus, it may prove helpful to promote adaptive problem-oriented coping activities in students when they feel depressed. At the level of coping strategies, the present findings also bear indirectly on the notion that depressed individuals are more likely to employ less adaptive coping strategies irt coping with depression. As expected, depressed students were more likely to USC’strategies of emotional containment and avoidance/denial. When such differences were t::plored within each sex, depressed females were characterized by their strat-
egy of passivity, which was also predictive of the depressive symptom level of female students. In cant rast. depressed males and nondepressed males did not differ significantly in their use of coping strategies, which were also not predictive of their depressive symptom level. The finding that passivity predicted depressive symptom level in females but not in males merits more attention in future studies. Caution, however, should be exercised in interpreting these sex differences as the sample of female students was very small. Less expected and somewhat at variance with the view of nonadaptive coping and depression was the lack of difference in the USCof apparently adaptive strategies of problem-solving and cognitive restructuring. The lack of difference might
indicate that both nondepressed and depressed individuals attempted to employ adaptive strategies but nondepressed individuals used these strategies more actively and therefore more effectively. Thus, both groups might use cognitive restructuring but only the nondepressed individuals would believe in the positive self-statements and the depressed individuals would accept the unhappy situation with a sense of resignation. Both groups might also use problem-solving, but the depressed individuals would feel less certain and more indecisive in taking action (Coyne et al., 15X31),and would rather wait to see whether problems would resolve by themselves. Thus, the use of problem-solving and cognitive restructuring could be easily undermined by brooding over problems and passivity. Although the present findings did not substantiatc significant sex differences in the use of coping strategies, the contrast between depressed and nondcpressed individuals separately in male and female students revealed indirectly certain possibly subtle differences in their coping activities. These sex differences were at best suggestive as the subsamples were very small. Nonetheless, the finding that depressed males tended to contain their emotions was consistent with the general view that it is less socially acceptable for Chinese men to express depression especially when the depressed mood is perceived to be caused by oncsclf not being able to meet life’s challenges. In contrast, females students’ expression of depression may be more socially acceptable, but depressed females would passively wait for problems to resolve by themselves. These subtle differences in the pattern of coping activities may have implications in the help-seeking behaviors of male and female students. Male students may be reluctant to seek professional help for their depressed mood because of social undesirability, while female students may keep procrastinating because of passivity. Some of the major limitations in the present study lit in its cross-sectional design and analyses, its reliance on self-report measures of coping, and the omission of person and contextual variables affecting coping. The cross-sectional design made it impossible to establish the direction of causality. While passivity was found to be one of
the coping strategies which predicted depressive symptom level among female students and differentiated depressed from nondepressed females, the question still remained whether female students who tended to use passive strategies became more depressed, or whether depressed females were more likely to use passive strategies and maintained their depressed mood. The alternative interpretation of an association between passivity and depression by d third factor such as personal control, or even the method of self-report, has not been ruled out in this study. Thus, depressed individuals may respond to the coping questionnaire in a biased way as they may not recall having engaged in any active strategies regardless of whether or not they have actually done so. Further, the assessment of contextual variables such as social support was omitted in this study. The sources and availability of social support may have important implications for the use of coping strategies as depressed persons have been reported to alienate needed sources of social support (Coyne, 1976). These issues, however, can only be resolved with longitudinal designs, the employment of behavioral measures and judgement data in the assessment of coping behaviors and cognitions, and the inclusion of person and situation factors as determinants of coping in future studies. The present findings also have implications for promoting adaptive coping activities and strategies among medical students in their stressful medical school environment. It appears that medical students genera!ly employed problem-focused activities, and depressed mood was associated with nonadaptive strategies of emotion containment and avoidance/denial, and possibly with the ineffective use of adaptive strategies. Thus, to of ensure effcctivc and active implementation adaptive strategies, coping skills aimed at active problem-solving, appropriate emotional regulation, and seeking out and maintaining social support should be systematically taught rather than being left solely to the students to be haphazardly acquired. Although this study was designed to focus on medical students, guidelines emerging from these findings are perhaps equally applicable to Chinese university undergraduates. While the generalizability of these results was limited by
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