Depression and its Correlation with Self-esteem and Social Support among Iranian University Students

Headnote

Objective: Considering the effects of the level of social support and selfesteem as risk factors in the onset and continuation of depression, the purpose of the current study (in addition to studying the demographic items of depression) was to investigate the correlation between depression and level of social support and self-esteem in Iranian university students studying non medical majors.

Method: The study was a cross-sectional descriptive-analytic research carried out on the students of Ferdowsi University of Mashhad in 2006. Self administered questionnaires on socio-demographic information (age, gender, marital status, and educational level), Eysenk self-esteem scale, Beck Depression Inventory and Cassidy social support scale were randomly given out to students who were selected by multi stage randomized sampling. The data were analyzed using SPSS version 14 using the χ2-test.

Results: 1200 students responded to the anonymous questionnaires. A total of 57.2% of the participants had depression (36.3% mild, 14.4% moderate and 6.5% severe). Depression was significantly higher in males, singles and in 25-29-year-old students. Results showed that 9.4%, 18.3% and 72.3% of the participants reported low, moderate and high levels of social support respectively. 1.8% and 6.3% of the participants reported low and moderate levels of self-esteem respectively; while 91.9% reported high levels of self-esteem.

Conclusion: Depression has a higher rate in non-medical university students of Iran than general population. Levels of social support and self-esteem were negatively associated with frequency of depression..

Keywords: Depression, Iran, Self-esteem, Social support, Students, Universities

Iran J Psychiatry 2009; 4: 17-22

Based on the WHO reports, depression is the fourth urgent health problem in the world (1). It makes severe changes in mood, affect, behavior and thought and is accompanied by many physical complaints (2, 3). Depression is known to be disabling, recurrent and in some cases chronic (4). It interferes with the patient's interpersonal relationships and has effects on the everyday activities of the sufferer (5). In addition to its high lifetime prevalence, depression occurs in all ages and all social classes. In numerous cases, its first episode occurs during adolescence and early adulthood (3, 4) and it is more common among women (6, 7).

Nowadays there is a raised attention to occupational stresses. The fact that human stressful experiences in the first years of their adult life could lead to the presence of depression (8) and the great influence depression has on one's attitude towards his/her profession, the concern about depression in college students is fundamental (3). On the other hand, students are prone to have more psychiatric problems including depression (9, 10) due to their interpersonal and emotional conflicts as well as economic and academic problems (7, 11-13).

Low level of social support is an important risk factor for depression (14-16). Social support includes sympathy, encouragement and support of colleagues, supervisors, friends and immediate family members (17). Higher levels of family support were shown to be associated with lower levels of depression and lower levels of suicide ideation (18, 19).

Researchers consider the human need for self esteem as a basic aspect of feeling well and a great desire to view the self positively. People prefer to make self-serving attributions to use self-enhancing and selfpresentational strategies and to make self-serving assessments of ability rather than having dysfunctional attitudes about their self image (2, 20). According to cognitive theories of depression, a certain negative way is considered as the main way in which self-concept is biased (20, 21). It has been accepted that depressive people think in a negative manner and report lower self-esteem than non-depressed people (10). Low self-esteem has also been associated with suicidal attempts especially in adolescents (22). Depression and self- esteem tend to be highly correlated with each other (23-25).

In different studies, lots of genetic and environmental factors which influenced the onset, course, and outcome of depression have been discussed. In comparison to genetic risk factors, environmental risk factors, considering their possible reversible nature, have a great role in prevention and treatment of depression. Therefore, as early detection and management of depression can lead to improvement in the field of general healthcare (26), in the current study we insisted to explore the correlation between the two important environmental risk factors of depression: 1) levels of social support and self-esteem, and 2) depression in university students.

Furthermore, in addition to studying the demographic items of depression in a large sample of students, we tried to investigate probable differences in epidemiological issues of depression in Iranian nonmedical university students compared to the same parameters in medical university students which had been reported previously. This comparison could further clarify the future directions for suitable interventions.

Materials and Method

Participants

The present study is a descriptive-analytic and crosssectional research carried out in Mashhad, the second largest city in Iran with a population of over 3 millions, in 2006. The target population was the students of Ferdowsi University of Mashhad.

It is worth mentioning that in Iran medical courses such as medicine, dentistry, obstetrics, etc are held in medical universities separate from non-medical majors such as veterinary, literature, engineering, basic sciences, etc. Medical study fields are officially under the supervision of ministry of health and non-medical fields of study are under the supervision of ministry of higher education.

There are two major universities in Mashhad: Mashhad University of Medical Sciences and Ferdowsi University for non-medical courses.

Considering the structural differences between medical and non-medical universities and the differences in their educational system including restriction of continuous doctorate courses with long periods (over 6 years) and medical students having to work night shifts, and also the fact that most studies on student depression have been done on medical students, we decided to perform our study on students of Ferdowsi university.

A total of 1300 students aged 18 and older were asked to complete the questionnaires. 1200 questionnaires were answered and response rate was 92.31%. Subjects who had chronic medical illnesses or severe disabilities, or had had major stresses in the last 6 months prior to research and females with premenstrual dysphoric disorder were excluded .

Procedures: In the first stage, the number of samples was calculated on the basis of other surveys on depression done in similar populations with 95% confidence interval, 5% error and 3% precision. A self administered questionnaire was randomly given out to students who were selected by multi stage randomized sampling proportional to the population size of each college and with respect to both age and gender of the respondents to maintain a sample representative of these two parameters. In the second stage, the goals of the study were explained to the potential participants.

Collected data were analyzed by appropriate descriptive and analytic statistical tests including χ2-test using SPSS version 14. Reported differences were significant at the 0.05 level or less.

Instruments

Everyone answered some questions about their sociodemographic information (age, gender, marital status, and educational level), Beck Depression Inventory (BDI), Eysenk self-esteem scale and Cassidy social support scale were also used.

Eysenk self-esteem scale has 7 items. The minimum score is 0 and the maximum is 140 (27). The reliability and validity of this scale have been examined in Iran by Sahebi (28) and Dolatabadi (29).

The Cassidy social support scale consists of 7 questions and is answered by "yes/not sure/no". Each question has 0 to 2 scores and the total score ranges between 0-14; which signifies poor (0-4), medium (5- 9) and satisfactory social support (10-14). The validity of this scale was confirmed by Cassidy in 1989 (30, 31). This scale's validity was confirmed by Korke Abadi (R=0.89) in Iran (32).

Beck Depression Inventory is still one of the most common and valid depression scales (33). It is applicable to all social levels and environments and is neither age nor culture based (34). It has a high content validity and good discriminative power to distinguish between depressed and non-depressed people (35). The scores between 0 to 9, 10 to 19 and 20 to 29 indicate normal, mild and moderate depression respectively. The score of 30 and more shows severe depression (36).

Results

Of the 1200 students who responded to the anonymous questionnaires, 36.7% (n=440) were male and 63.3% (n=760) female, 89.2% (n=1071) single and 10.8% (n=129) were married. Demographic variables are shown in Table 1. A total of 57.2% of the participants had depression (36.3% mild, 14.4% moderate and 6.5% severe). It was shown that some degrees of depression was present in 53.6% (n=406) of the females and 63.6% (n=280) of the males. Rate of depression was higher in males and the difference was significant (P=0.001, χ2=16.209, df=3). 57.4% (n=615) of the single students and 55% (n=71) of the married ones reported depression respectively. Rate of depression was higher in singles and the difference between the two groups was significant (P=0.405, χ2=9.355, df=9). In the present study, students were divided into three age groups: 1) under-20, 2) 20-24 and 3) 25-29 age groups. Depression was experienced less in the age group of under-20 and was more reported in the 25-29 age group. In terms of depression, the difference between the three groups was significant (P=0.002, χ2=20.347, df=6).

The results showed that 9.4% (n=113) of the participants reported low levels of social support, 18.3% (n=219) reported moderate levels and 72.3% (n=868) reported high levels of social support. There was a significant negative relation between levels of depression and social support (P=0.000, χ2=118.135, df=6) (Table 2).

According to our results 1.8% (n=22) of the participants reported low levels of self-esteem, 6.3% (n=75) reported moderate levels and 91.9% (n=1103) reported high levels of self-esteem. A significant relation between level of self-esteem and depression was found (P=0.000, χ2=113.209, df=6) (Table 3).

Discussion

The self-reported mild, moderate, and severe depression rates were 36.3%, 14.4% and 6.5% respectively among students of Ferdowsi University of Mashhad. Men reported depression more than women (63.6% vs. 53.6%). Single students experienced more depression than the married (57.4% vs. 55%). 42.8% of the students did not report any depression. The observed high rates of depression were comparable to previously published studies over the last 20 years on Iranian university students (37-39). High rates of depressive symptoms among college students were reported by other researchers in different countries as well. 55%, 49% and 50.1% of the students in Rockville, Rochester and Thailand reported different levels of depression respectively (10, 40, 41). Nevertheless, according to most publications, prevalence of depression in general population is 15- 25% which is lower than the rates of our study (42, 43). However, in comparison to general population norms, the students' reports of higher symptom levels cannot be assumed to indicate higher levels of more serious mental health conditions. As attending university is usually the first major transition in the lives of students, the way they navigate this transition may be a risk factor for feeling depressed (44) and this is not to deny the genuine distress and severe problems that some students experience (9).

Mild depression was reported to be 6 times more prevalent than severe depression and it was more prevalent in the 20-24 age group. This could be considered as a kind of maladaptive behavior in the first years of entering colleges (44). As the impact of perceived social efficacy was mediated through low level of depression and perceived self-regulatory efficacy was related to academic achievement, special attention to even mild depression is necessary (45).

Our study revealed that the incidence of depression was higher in men and the difference had a statistical significance. This finding was not in accordance with other reports which found that women experienced higher depression levels than men during their educational years (7, 46, 47). Age was associated with depression. Depression was more prevalent in the 25- 29 age group, and so was the moderate and severe depression although mild depression was more prevalent in the 20-24 age group. In the Lodz Medical University, 28.8% of the 2nd year students and 14% of the 4th year medical students were diagnosed with depressive symptoms which showed a decrease in selfreported depressive symptoms during their educational years (48); however, our findings were not in accordance with theirs. These interesting findings could notify an important point of view which concerns the increased worries and stresses during the educational years especially in male students. Many factors may relate to this deterioration. One of the probable factors is that male students had lower social support levels than female students (based on our findings); and this could be a cultural issue. In other words, Iranian men may believe that receiving support such as sympathy or encouragement from others even from first degree relatives could interfere with their role of being "a man". Another possible factor which could explain our results is that older students had lower self-esteem levels than younger ones so did male students in comparison to female ones. Job satisfaction was strongly associated with self-esteem (49) and men showed a greater association of depression with longterm unemployment than women (50). Based on the results obtained in Iran, students' attitude towards the social ranking of their field of education, as an indicator of their professional perspective, was worsened after entering college , and this was also true for males (51).

There was also a significant difference in depression rates between single and married students. This finding is in accordance with those reported by previous surveys (52-54). High marital quality was associated with lower stress, less depression, higher satisfaction with life and higher supportive network. Likewise, marriage may be distinctive as evidence further suggests that the support from one's network does not compensate for the effects of being single (55). Findings support the idea of marriage protecting individuals against psychological distress (18, 50, 56- 58).

9.4 %of the participants reported low levels of social support and moderate and high levels were reported in 18.3% and 72.3% of the subjects respectively. Multivariate analysis demonstrated that family and peer connections protected the students against depression (46). Emotional support of family members can improve mental health by reducing anxiety, stress and depression (10, 55, 59). Behaviors such as substance abuse or burnout symptoms in depressives were related to a lack of social support and external attribution style (41).

In previous studies, students reported the greatest perceived negative academic impact related to experiencing interpersonal concerns (concerns about troubled friends or family members, death of a friend or family member, and relationship difficulties) and mental health concerns (depression, anxiety, seasonal affective disorder and stress) (60). Our research produced similar results. This study demonstrates the importance of health education and health promotion programs including prevention of initiation as well as treatment for students attending universities. These interventions demonstrated promising effects on changing the patterns of specific challenges associated with acute adjustment as well as long-term stressors. Many university students lack knowledge about depression and its treatment. Therefore, simple and cheap media, such as postcards and posters might help to improve awareness in areas where current knowledge is low (4) and counseling services should be provided in every college of each university to assist students to handle issues that constitute a source of stress in their psychosocial environment (61).

Conclusion

Results showed that depression has a high rate in Iranian university students studying non-medical majors. Levels of social support and self-esteem were negatively associated with frequency of depression

References

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