Title: Vicissitudes of depressive symptoms during a medical course - a cross sectional study

Transcription

1 Author's response to reviews Title: Vicissitudes of depressive symptoms during a medical course - a cross sectional study Authors: Sergio Baldassin (spbaldassin@uol.com.br) Tânia CTF Alves (tania_alves@hotmail.com) Arthur G Andrade (aandrade@usp.br) Luiz A Nogueira-Martins (nogmartins@psiquiatria.epm.br) Version: 4 Date: 26 September 2008 Author's response to reviews: see over

2 September 25, 2008 To the Editor of BMC Medical Education Many thanks for our kind reviews of the manuscript Vicissitudes of depressive symptoms during medical Course a cross sectional study. We would like to submit a revised manuscript of our paper named now The characteristics of Depressive Symptoms in Medical Students during Medical Education and Training: a Cross sectional Study. We believe that we have contemplated the comments made by the two reviewers and we also believed that our revise manuscript have improved quality. On the following lines we with answer the questions by the referees.

3 REVIEWER 1 Reviewer: Charlotte E Rees In regard to the limitations listed by this reviewer: Many thanks for your comments. We believe that we have achieved a better quality manuscript after contemplating the following points. 1. We agree and thank the reviewer in rephrase the Title. The new title is: The Characteristics of Depressive Symptoms in Medical Students during Medical Education and Training: a Cross sectional Study is more favorable. 2. We thank the reviewer for reminding us about a the use of a word grade instead year and explain better about the Brazilian study periods characteristics and clusters (affective, cognitive and somatic) which proved to be very useful in our abstract. 3. We have enriched the Introduction given the multitude of relevant papers in this area and their findings, increasing properly discussed, critiqued and originality aspects. We with the reviewer the statement that medical education is divided up into basic, intermediate and internship periods was simplistic categorization, we modified and increased with more information the context of our study, better describing the program and the other issues that may lead depression in medical students, like work overload and traumatic events. And finally we included a clusters description in this upfront section. 4. We acknowledge that several issues of the Method section needed to be better interpreted and we sought to clarify in our manuscript the main concerns of the reviewer, regarding the acronyms ABC means, about the response rate of this study, internal consistency of BDI Portuguese version, multiple regression analysis methods, and possible range scores of clusters and periods of the medical course. We included a better explanation of these aspects. And due to the anonymity of the research we don t try to survey those absent students just described those population about gender and age which comparison was not significant (p=.192). We conducted a multiple-regression analysis using the BDI total score as dependent variable involving gender, age, course periods, years of study between high school and entering medical school, first degree relative working as a physician, living alone or with family as independent factors ( enter method ) initially to

4 find risk or protector factors influencing the original BDI scale and after a logistic regression for BDI > 16 using the cut of to create a pragmatic clinical parameter based in the those used during a Portuguese validation: BDI > 16 to detect a disphoric range and BDI > 20 to detect a considered depression range [31]. Using this cut of we have obtained a ROC curve with a sensibility of 75% and specificity at 53%. About the use of three models of cluster analysis where the dependent variable is the cluster scores, a model for each affective, somatic and cognitive aspect may sound unrealistic and it is reasonable think they are much integrated. 5. The reviewer questioned in the Results section about the mean of years studying before getting into medical school and we agree to reconstruct this phrase which means have at least a two-year gap between the end of high school and entering into Medical School. The punctuation was revised. We agree and thank the reviewer suggesting to resize the group analysis to three periods only (text and Tables 1 and 2) and to explain better the model of logistic regression at page 13 actually logistic regression instead linear regression trying construct a practice model....need a table for the regression model(s) as this would make it clearer what the authors have done and what they found in terms of multivariate statistics: We have now included in the results section the details regarding to the logistic regression (page 11 and 13), as well as the specificity and sensibility of ROC curve at BDI>16 (page 10 and 11). The interpretation of both BDI score as means and standard deviation, and a second analysis using a cutoff for depression in BDI>16 was in according to the proposition of the experience of depression as a continuum, and that sub threshold or subsyndromal depression differs quantitatively rather than qualitatively from major depression The hypothesis was that the nature of the depressive experience would differ in intensity (quantitatively), but not in kind (qualitatively), in individuals with mild versus severe depression. 6. We provided modifications at Discussion section (pages 13 to 19) believing that we have contemplated the suggestions made and also we sent the manuscript to an international professional English editing. Reading the discussion the question of why? repeatedly popped up into my mind and the authors should try and postulate reasons behind their findings: We now extended our discussion in order to provide some possible exploratory reasons behind our findings. For example we explore the core cluster analysis of depression in our study. The higher affective cluster of depressive scores in the internship may affect since the beginning

5 the feelings of pleasure and compassion of the doctor patient relationship. The higher cognitive cluster during the internal ship occurs at the same time of deceptions with the institution and health system, fears of the professional future, failures, performance, even dislike own appearance, this in general not good, due the lack of sleep and leisure and fewer physical and sexual activities. Taken all together, it might suggest that the possible development of coping mechanisms during the medical course is responsible for lower scores in the intermediate period. The medical course, by itself, can directly contribute to the development of depression and behavioral problems, such as alcohol and drug abuse. During the first semester there are significant changes in the student s daily habits. Other issues may lead to the development of depressive symptoms among medical students, such as work overload, competitive environment, constant pressure of examination/assessment, as well as the vicissitudes of the coursework, which exposes students to several sources of distress from the admission process to graduation, including dealing with traumatic events such as death and dying, ethical dilemmas, dissecting cadavers, pathologic processes, the first physical examination on a patient, the fear of acquiring diseases, feelings of inadequacy, medical hierarchies, bullying and harassment. The study also showed that female students were more susceptible towards developing depression symptoms than male students. Gender comparisons in the academic profession, prior to, during and after the medical course shows that the gap between man and woman in medicine is getting narrower. Even though academically there is no significant gender differences, several noncognitive aspects often shows a different pattern among men and women. In our sample there were 60% female students, however there was no significant difference between male/female (p=.242). The current study was based on anonymous self answer questionnaires that might be associated to a bias of minimizing or maximizing symptomatology. In Brazil, there is a very special condition the vestibular examination has to be passed after high school in order to enter any Brazilian medical school. Even though the medical profession is highly distressful, there are many students competing for each medical school vacancy. Therefore many students spend a vary number of years between finishing high school and entering medical course. This students experience every year a sense of failure and impotence when not succeed to enter the desired course. 7. We modified the Table 1 and Table 2 Level of interest: An article of importance in its field Quality of written English: Not suitable for publication unless extensively edited Statistical review: Yes, and I have assessed the statistics in my report. Declaration of competing interests: I declare that I have no competing interests.

6 REVIEWER 2 Reviewer's report Reviewer: Alan Apter Reviewer's report: This is a nice study with a well defined question, addressing an interesting and important topic. The study surveyed medical students with the Beck Depression Inventory and a demographic questionnaire. A weakness of the study is that it is cross sectional, but as a survey the methods are well founded. A control group of students from other faculties might also have been in order. The data are sound, the n is large, the statistics are well done and the BDI is an accepted and well validated instrument. The ms meets accepted standards. The discussion is adequate although the attempt to include a detailed analysis of the different subscales of the BDI seems a little forced. I think that the limitations section could be expanded to include the above and other comments. The references are adequate and the title and abstract are fine. There are some typos and the ms could be approved by tighter English editing. Level of interest: An article of importance in its field Quality of written English: Needs some language corrections before being published Statistical review: No, the manuscript does not need to be seen by a statistician. Declaration of competing interests: 'I declare that I have no competing interests' In regard to the limitations listed by this reviewer: Many thanks for your comments. We believe that we have achieved a better quality manuscript after contemplating the following points: 1- We agree that a weakness of our study is the cross sectional designs and the absence of a control group for different course. We now included these two aspects in the revised manuscript in the discussion section (page 14). 2- We included a further discussion regarding to the advantages/ disadvantages in assessing BDI subscales (page 13). 3- We send out revise manuscript to a professional English editing and now we resubmitted after that.