Accepted: 21 December 2016 DOI: 10.1111/eje.12259
ORIGINAL ARTICLE
Burnout, depression and suicidal ideation in dental and dental hygiene students George R. Deeb1 | Sarah Braun2 | Caroline Carrico3 | Patricia Kinser4 | Daniel Laskin1 | Janina Golob Deeb3 1 Department of Oral and Maxillofacial Surgery, Virginia Commonwealth University, Richmond, VA, USA 2
Abstract Introduction: The aim of this study was to assess the relationship between burnout,
Department of Psychology, Virginia Commonwealth University, Richmond, VA, USA
depressive symptoms and suicidal ideation in dental and dental hygiene students and
3
Subjects and methods: Third- and fourth-year dental (DS) and first- and second-year
Department of Periodontology, Virginia Commonwealth University, Richmond, VA, USA 4 School of Nursing, Virginia Commonwealth University, Richmond, VA, USA
Correspondence Janina Golob Deeb, Department of Periodontology, Virginia Commonwealth University, Richmond, VA, USA. Email:
[email protected]
to evaluate the influence of gender, programme type and year of study. hygiene students (DHS) completed the Patient Health Questionnaire (PHQ-9) and an abbreviated Maslach Burnout Inventory online as measures of depressive symptoms/ suicidality and burnout, respectively. The statistical analyses included summary statistics and tests for intergroup comparisons (chi-square) to evaluate the influence of gender, programme type (DHS or DS) and year of study. Correlations between depression, suicidality and burnout were also conducted. Results: A total of 32 dental hygiene and 119 dental students participated. 40% of the dental and 38% of the hygiene students met criteria for burnout. No differences were found between years or between programmes. Nine per cent of both dental and hygiene students were above the cut-off for moderate depressive symptoms, but there were no statistical differences between the third- and fourth-year dental and the first and second-year hygiene students. Six per cent of the dental and 9% of the dental hygiene students were above the cut-off for clinically significant suicidal ideation, but there were no statistical differences between dental and hygiene students. There were no differences noted in the dental students based on gender for any of the measures. Depression was significantly associated with all three subscales of burnout. Suicidal ideation was only significantly related to the lack of personal accomplishment subscale of burnout. Discussion: These findings suggest the need for introducing preventive measures for such affective states in dental and dental hygiene training programmes. KEYWORDS
students, dental education, stress, burnout, depression, dental hygiene
1 | INTRODUCTION
for learning,1 the negative consequences of stress in dental education are significant.2 One of the possible long-term negative consequences
The challenges of studying dentistry and dental hygiene place stu-
of stress is burnout, defined as a combination of emotional exhaustion,
dents at high risk for negative affective states. Although it has been
depersonalisation and a decreased sense of personal accomplishment.3
hypothesised that some stress may actually be beneficial as a stimulus
Burnout is well recognised as an occupational risk factor for practicing
Eur J Dent Educ 2017; 1–5
wileyonlinelibrary.com/journal/eje
© 2017 John Wiley & Sons A/S. | 1 Published by John Wiley & Sons Ltd
|
DEEB et al.
2
dentists.4–6 Interest in identifying burnout amongst predoctoral dental 7–12
ment subscale are not considered burnout, because this may be meas-
students has increased in many countries over the years.
Depression during dental education is also a concern. One study reported the prevalence of depression in dental students in Spain and found that it was higher in the second and fourth years of training compared to the fifth year.
11
with the previous literature, low scores on the personal accomplish-
These same authors found that suicidal
uring a distinct dimension.3 Therefore, the personal accomplishment subscale was not administered in this study. The Patient Health Questionnaire-9 (PHQ-9) was used to measure depressive symptoms and suicidal ideation.15 The PHQ-9 is a well-
11
validated nine-item questionnaire that asks respondents to indicate
Burnout and stress have been studied in European dental stu-
how frequent statements specific to the diagnosis of depression occur
dents;8,10 however, limited data on the prevalence of burnout, de-
(eg “feeling down, depressed, or hopeless”) on a four-point Likert scale
ideation was also more prevalent during the second and fourth years.
pression and suicidal ideation amongst US dental and dental hygiene
ranging from “not at all” to “all the time.” The final item on the PHQ-9
students exist.11 Extant literature regarding US medical students sug-
assesses suicidal ideation using the same scale. Total scores ranging
gests that up to 50% of medical students report burnout and 11.2%
from 1 to 4 are considered normal levels of depression, 5-9 are con-
report suicidal ideation.7 However, the relationship between burn-
sidered to be mild levels, 10-14 moderate levels, 15-19 moderately
out, depression and suicidal ideation is unknown in healthcare pro-
severe levels and 20-27 severe depressive symptoms. On the single
fessionals. The aims of this study were to determine the prevalence
item measuring suicidal ideation, any score above a zero (ranging from
of burnout, depressive symptoms and suicidal ideation in third- and
1 to 3) was considered clinically relevant for this study.
fourth-year dental students and first- and second-year dental hygiene students at a large south-eastern urban university; to assess whether there is an association between burnout, depressive symptoms and
2.2 | Statistical analysis
suicidal ideation in these students; and to evaluate whether gender is
Descriptive statistics were calculated to determine the demograph-
a predictor of prevalence of these conditions.
ics of the sample and the prevalence of burnout, depressive symptoms and suicidal ideation. Chi-squared tests were used to test for
2 | SUBJECTS AND METHODS
differences in prevalence based on gender, type of programme (dental hygiene or dental students) and year in the study. Where appropriate, Fisher’s exact test was used to account for small cell counts.
All third- and fourth-year dental students and all first- and second-
Spearman correlations were calculated to determine the correlation
year dental hygiene students enrolled at the Virginia Commonwealth
between depressive symptoms and the burnout measures. A level of
University School of Dentistry were invited via email to participate in
0.05 was used for statistical significance, and all analyses were per-
an online survey. In the email, the aims of the study were described
formed in SAS Enterprise Guide v6.1.
and students were asked for their anonymous participation. Data collection took place over a 2-week period in February 2015. This study was approved by the Institutional Review Board at Virginia
3 | RESULTS
Commonwealth University. A total of 151 students participated in the study of 248 eligible stu-
2.1 | Measures
dents (overall response rate of 61%). Of these, 21% (n=32) were first- or second-year dental hygiene (DH) students and 79% (n=119)
In addition to demographic information, data were collected that
were third and fourth year dental students (D3, D4). The programme-
measured burnout, depressive symptoms and suicidal ideation. The
specific response rates were 67% (32/48) for dental hygiene students
Maslach Burnout Inventory—Human Services (MBI) survey measures
and 60% (119/200) for dental students. Demographics of the sam-
burnout in three domains: emotional exhaustion, depersonalisation
ple were reflective of what would be expected based on population
and lack of personal accomplishment.3 The MBI is traditionally a 22-
norms. The dental hygiene participants were all female, whereas a
item measure asking respondents to rate the frequency of several
more even gender distribution was seen in the dental students (44%
feelings and experiences on a seven-point Likert scale ranging from
male, 56% female). None of the psychological variables differed sig-
“never” to “daily.” This instrument is the gold standard for measuring
nificantly in dental students based on gender. Complete demographic
burnout in medical professionals and is well validated in this popula-
breakdown is given in Table 1. A complete summary of the measured
13
tion.
To decrease participant burden, a single-item, or proxy, meas-
scales (burnout, depression/suicide) is presented in Table 2.
ure for the emotional exhaustion (“I feel burned out from my work”) and depersonalisation (“I have become more callous toward people since I took this job”) subscales was used. These one-item measures of
3.1 | Burnout
the emotional exhaustion and depersonalisation subscales of the MBI
Amongst the dental hygiene students, an estimated 22% met the cri-
have been validated in a healthcare professional population.14 In line
teria for emotional exhaustion and for depersonalisation. For the den-
with the current literature, a response that indicated “once a week” or
tal students, 34% met the criteria for emotional exhaustion and 17%
more was considered meeting the criterion for burnout.14 Consistent
for depersonalisation. The observed prevalence of burnout, defined
|
3
DEEB et al.
T A B L E 1 Summary of demographics by programme Dental hygiene Respondents n (%) Average age (SD)
we found that 6% (n=7, 95% CI: 1.6%-10.2%) of D3/D4 students and
Dental students
32 (21%)
119 (79%)
23.6 (3.9)
Male
27.8 (3.7)
which depressive symptoms and suicidal ideation were determined, demonstrated good internal consistency (α=0.82) in the present
32 (100%)
67 (56%)
0 (0%)
52 (44%)
29 (91%)
65 (55%)
sample.
Marital status n (%) Single
templated suicide on several days or more. The difference between the type of student was not statistically significant. The PHQ-9, from
Gender n (%) Female
9% (n=3, 95% CI: 0.0%-20.1%) of dental hygiene students had con-
Living with partner
0 (0%)
8 (7%)
Married
2 (6%)
44 (37%)
Divorced/separated
1 (3%)
1 (1%)
Other
0 (0%)
1 (1%)
3.3 | Correlation between depressive symptoms and burnout Spearman correlations were calculated between the depressive symptoms score (PHQ-9) and the burnout measures (MBI Subscales). Depressive symptoms were significantly positively correlated with the burnout subscales of depersonalisation (r=.30) and emotional exhaus-
Some categories may add to greater than 100% due to rounding.
tion (r=.37). Depressive symptoms were significantly negatively correlated with the burnout subscale of personal accomplishment (r=−.31).
as meeting criteria for either the emotional exhaustion or deperson-
Personal accomplishment was also found to be significantly negatively
alisation subscales, was 40% (95CI: 30.5%-48.4%) for dental students
correlated with suicidal ideation (r=−.20). None of the other measures
and 38% (95% CI: 19.8%-55.2%) for dental hygiene students. There
were significantly correlated with suicidal ideation. Spearman correla-
were no significant differences between the DH1/DH2 and D3/D4
tions are given in Table 3.
groups or between the DH1 and DH2 students and between the D3 and D4 students. Because single-item measures for the two subscales of burnout were used, internal consistency cannot be determined.
4 | DISCUSSION
However, in previous research, the single- item measures demonstrated moderate-to-strong correlations with the full measures.15
The prevalence of burnout in dental students and dental hygiene stu-
3.2 | Depressive symptoms/suicide
is one of only a few to report burnout rates in dental students in the
dents has not been widely reported. To our knowledge, this report USA. Results from this cross-sectional study suggest that burnout is
Approximately 53% of both dental students and dental hygiene stu-
an issue faced by 38%-40% of dental and dental hygiene students.
dents were classified as having none/minimal depression. A majority
Most of the students surveyed in the present study did not report
of those scoring above minimal depression were only mildly depressed
clinically significant symptoms of depression; however, the 10%-12%
(34% for DH and 37% for D3/D4s). For dental hygiene students, 6%
incidence of moderate-to-moderately severe depressive symptoms
were moderately depressed and 6% had moderately severe depres-
reported warrants attention, particularly given the relationship of de-
sion. Similarly for the D3/D4 respondents, 7% were moderately de-
pressive symptoms to burnout and suicidality. Nine per cent of the
pressed and 3% had moderately severe depression. There was no
dental students reported clinically significant suicidal ideation, sug-
significant difference between the DH and D3/D4 groups or between
gesting that they may be at a greater risk than the national average.
the DH1 and DH2 students and between D3 and D4 students. Based
These rates are slightly higher than reports from other countries; one
on the definition of suicidal ideation as stated in the Methods section,
study observed rates of burnout in Spanish dental students between
T A B L E 2 Rates (n, %) of burnout, depression and suicidal ideation in dental students and dental hygiene students, reported overall and by year Dental hygiene students overall
DH1 students
DH2 students
Dental students overall
D3 students
D4 students
Emotional exhaustion proxy n (%)
7 (22%)
4 (24%)
3 (20%)
40 (34%)
24 (36%)
16 (31%)
Depersonalization proxy n (%)
7 (22%)
3 (17%)
4 (27%)
20 (17%)
8 (12%)
12 (23%)
Personal accomplishment n (%)
8 (25%)
5 (29%)
3 (20%)
26 (22%)
13 (19%)
13 (25%)
Burnout proxy (DP/EE proxy) n (%)
12 (38%)
6 (35%)
6 (40%)
47 (40%)
27 (40%)
20 (38%)
Depression n (%) (moderately or severely depressed)
4 (12%)
1 (6%)
2 (13%)
12 (10%)
7 (11%)
4 (8%)
Suicidal ideation n (%) (contemplated several days or more per week)
3 (9%)
1 (6%)
2 (13%)
7 (6%)
5 (7%)
2 (4%)
|
DEEB et al.
20% and 31%, depression between 3% and 9% and suicidal ideation between 3% and 8%.11 None of the psychological variables in our study were affected by gender, which is in agreement with previous research.6,8,11
0.32*
Suicidal ideation (Y/N)
4
As expected, the results of the correlational analyses showed a moderate positive relationship between depression and all three doare related constructs. Burnout is confined to the domain of work, whilst depression is pervasive across the domains of life. It could be that burnout leads to depression or vice versa. As these results are
0.06
0.27*
Burnout (Y/N)
mains of burnout. These results suggest that burnout and depression
only cross-sectional, the temporal relationship cannot be determined. tervention development for healthcare professional with burnout. Perhaps elements of treatment for depression, such as behavioural activation or meaning-making, could be important in the treatment of burnout as well. Interestingly, the item measuring suicidal ideation was only sig-
0.04
0.30*
Depersonalization burnout subscale
However, this relationship is important to consider, especially in in-
nificantly related to one subscale of burnout: lack of personal accom-
suicidal ideation. As these findings are cross-sectional, conclusions are preliminary. However, this pattern of result suggests that lack of meaning and positive self-concept derived from one’s work are im-
−0.31*
portant in the relationship with suicidal ideation. These findings point to the importance of meaning-making in the treatment of chronic
−0.20*
Personal accomplishment burnout subscale
plishment. These findings suggest that the lack of meaning derived from one’s work is the important domain of burnout when considering
stress for dental students and perhaps healthcare professional students in general.16
be determined. Future studies should investigate the relationship of burnout, depression and suicide in dental and dental hygiene students a non-random subject sample, and participants self-selected to partic-
0.16
0.37*
at multiple time points to strengthen our conclusions. Also, as this was ipate, selection and non-response bias cannot be eliminated as possithe respondents seemed to be representative of the typical student population in terms of gender and marital status, which reduces the effect of these limitations. Moreover, because these are findings from a single institution, the results may not be representative of all US dental schools. However, validated measures were used, which should allow for comparison with other dental schools, other healthcare professionals-in-training and the general population. It may be important to use the full version of the burnout scale in the future studies *Statistically significant at 0.05 level.
Suicidal Ideation (PHQ-9 Question 9: thoughts that you would be better off dead or of hurting yourself in some way.)
ble confounding variables. However, the response rate was high and
Depressive symptoms (PHQ-9)
Emotional exhaustion burnout subscale
T A B L E 3 Spearman correlations between depressive symptoms and burnout
This study is not without limitations. Because it was only a cross- sectional self-report survey of symptoms, no causal relationships can
to address potential limitations regarding the single-item measures of burnout subscales; however it is notable that these single-item measures are well validated in the healthcare professional populations and was used to reduce participant burden, a common issue in research on this population. Finally, the sample size was relatively low, especially amongst the dental hygiene students limiting the statistical power and precision of the estimates. In conclusion, given that the relatively high percentage of burnout and suicidal ideation in the current sample of dental and dental hygiene students is replicated in the literature amongst other healthcare
|
5
DEEB et al.
professions, including medical and nursing students,17,18 there is a need to target preventive interventions for healthcare professional students during their training. Systematically teaching skills in stress management, self-care and psychological well-being may benefit this population of students by increasing coping strategies and decreasing burnout.16 Based on our findings, future research should investigate the effects of stress management and burnout interventions on these psychological measures. Future research should also investigate the effects of provider stress and burnout on dental patient treatment outcomes, as the literature from the medical and nursing professions suggests that burnout may have a negative effect on patient care and healthcare professionals’ performance.
REFERENCES 1. Saito A, Fujinami K. Introduction of formal debate into a postgraduate specialty track education programme in periodontics in Japan. Eur J Dent Educ. 2011;15:58–62. 2. Alzahem AM, van der Molen HT, Alaujan AH, Schmidt HG, Zamakhshary MH. Stress amongst dental students: a systematic review. Eur J Dent Educ. 2011;15:8–18. 3. Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory Manual, 3rd edn. Palo Alto, CA: Consulting Psychologists Press Inc; 1996. 4. Schaufeli WB, Enzmann D. The Burnout Companion to Study and Practice: A Critical Analysis. London: Taylor & Francis; 1998. 5. Gorter RC, Albrecht G, Hoogstraten J, Eijkman MAJ. Professional burnout among Dutch dentists. Community Dent Oral Epidemiol. 1999;27:109–116. 6. Humphris G. A review of burnout in dentists. Dent Update. 1998;25:392–396. 7. Pohlman K, Jonas I, Ruf S, Harzer W. Stress, burnout and health in the clinical period of dental education. Eur J Dent Educ. 2005;9:78–84. 8. Humphris G, Blinkhorn A, Freeman R, et al. Psychological stress in undergraduate dental students: baseline results from seven European dental schools. Eur J Dent Educ. 2002;6:22–29.
9. Badran DH, Al-Ali MH, Duaibis RB, Amin WM. Burnout among clinical dental students at Jordanian universities. East Mediterr Health J. 2010;16:434–437. 10. Gorter R, Freeman R, Hammen S, Murtomaa H, Blinkhorn A, Humphris G. Psychological stress and health in undergraduate dental students: fifth year outcomes compared with first year baseline results from five European dental schools. Eur J Dent Educ. 2008;12:61–68. 11. Galán F, Ríos-Santos JV, Polo J, Rios-Carrasco B, Bullón P. Burnout, depression and suicidal ideation in dental students. Med Oral Patol Oral Cir Bucal. 2014;19:e206–e211. 12. Davis EL, Tedesco LA, Meier ST. Dental student stress, burnout, and memory. J Dent Educ. 1989;53:193–195. 13. Rafferty JP, Lemkau JP, Purdy RR, Rudisill JR. Validity of the Maslach Burnout Inventory for family practice physicians. J Clin Psychol. 1986;42:488–492. 14. West CP, Dyrbye LN, Sloan JA, Shanafelt TD. Single item measures of emotional exhaustion and depersonalization are useful for assessing burnout in medical professionals. J Gen Intern Med. 2009;24:1318–1321. 15. Kroenke K, Spitzer RL, Williams JB. The Phq-9. J Gen Intern Med. 2001;16:606–613. 16. Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009;302:1284–1293. 17. Dyrbye LN, Massie FS, Power DV, et al. Burnout and suicidal Ideation among U.S. medical students. Ann Intern Med. 2008;149:334–341. 18. Dyrbye LN, Watson R, Hohston R. A longitudinal cohort study of burnout and attrition in nursing Students. J Adv Nurs. 2003;43:71–81.
How to cite this article: Deeb GR, Braun S, Carrico C, Kinser P, Laskin D, Golob Deeb J. Burnout, depression and suicidal ideation in dental and dental hygiene students. Eur J Dent Educ. 2017;00:1–5. doi: 10.1111/eje.12259.
