International Journal of Psychiatry in Clinical Practice

ISSN: 1365-1501 (Print) 1471-1788 (Online) Journal homepage: http://www.tandfonline.com/loi/ijpc20

Prevalence of depressive symptoms among

medical students taught using problem-based
learning versus traditional methods

José Aderval Aragão, Marianna Ribeiro de Menezes Freire, Lucas Guimarães

Nolasco Farias, Sarah Santana Diniz, Felipe Matheus Sant’anna Aragão,
Iapunira Catarina Sant’anna Aragão, Tarcisio Brandão Lima & Francisco
Prado Reis

To cite this article: José Aderval Aragão, Marianna Ribeiro de Menezes Freire, Lucas
Guimarães Nolasco Farias, Sarah Santana Diniz, Felipe Matheus Sant’anna Aragão, Iapunira
Catarina Sant’anna Aragão, Tarcisio Brandão Lima & Francisco Prado Reis (2017): Prevalence
of depressive symptoms among medical students taught using problem-based learning
versus traditional methods, International Journal of Psychiatry in Clinical Practice, DOI:
10.1080/13651501.2017.1383438

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Published online: 03 Oct 2017.

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 INTERNATIONAL JOURNAL OF PSYCHIATRY IN CLINICAL PRACTICE, 2017
https://doi.org/10.1080/13651501.2017.1383438

ORIGINAL ARTICLE

Prevalence of depressive symptoms among medical students taught using

problem-based learning versus traditional methods
Jos

e Aderval Arag~aoa, Marianna Ribeiro de Menezes Freireb, Lucas Guimar~aes Nolasco Fariasb,
Sarah Santana Dinizb, Felipe Matheus Sant’anna Arag~aoc, Iapunira Catarina Sant’anna Arag~aoc,
Tarcisio Brand~ao Limad and Francisco Prado Reise
a
Postgraduate Program on Sciences Applied to Healthcare, Department of Morphology, Federal University of Sergipe (UFS), Aracaju, SE, Brazil;
b
Department of Medicine, Tiradentes University (UNIT), Aracaju, SE, Brazil; cDepartment of Medicine, University Center of Volta Redonda
(UNIFOA), Volta Redonda, RJ, Brazil; dDepartment of Medicine, Tiradentes University (UNIT), Aracaju, SE, Brazil; ePostgraduate Program on
Health and the Environment, Department of Medicine, Tiradentes University, Aracaju, SE, Brazil
Downloaded by [Australian National University] at 17:40 06 October 2017

ABSTRACT ARTICLE HISTORY

Objective: To compare depressive symptoms among medical students taught using problem-based learn- Received 5 January 2017
ing (PBL) and the traditional method. Revised 1 August 2017
Material and methods: Beck’s Depression Inventory was applied to 215 medical students. The prevalence Accepted 18 September 2017
of depression was calculated as the number of individuals with depression divided by the total number in
the sample from each course, with 95% confidence intervals. The statistical significance level used was 5% KEYWORDS
(p
.05). Depressive symptoms;
Results: Among the 215 students, 52.1% were male and 47.9% were female; and 51.6% were being depression; medical
taught using PBL methodology and 48.4% using traditional methods. The prevalence of depression was students; problem-based
29.73% with PBL and 22.12% with traditional methods. There was higher prevalence among females: learning
32.8% with PBL and 23.1% with traditional methods. The prevalence of depression with PBL among stu-
dents up to 21 years of age was 29.4% and among those over 21 years, 32.1%. With traditional methods
among students up to 21 years of age, it was 16.7%%, and among those over 21 years, 30.1%. The preva-
lence of depression with PBL was highest among students in the second semester and with traditional
methods, in the eighth.
Conclusions: Depressive symptoms were highly prevalent among students taught both with PBL and
with traditional methods.

Introduction symptoms are generally most prevalent among medical students.

Depression is a mood disorder of variable intensity and duration
characterized by a diversity of mental symptoms that affect indi-
viduals’ capacities ranging from feeling pleasure to doing plan-
ning (Garro, Camillo, & No
brega, 2006). It is also characterized by
slowing down of mental processes. It may give rise to moods of
depression, irritation or despondency; lack of interest; difficulty in
concentrating; thought of a negative nature; loss of capacity to
plan for the future; and alteration of the sense of reality (Canale &
Furlan, 2006).
Upon entering higher education courses, students frequently
display personal and academic difficulties of different natures,
relating mainly to their academic experience and adaptive cap-
acity (Almeida, Soares, & Ferreira, 2002; Soares, Poube, & Mello,
2009; Vendramini et al., 2004). It has been estimated that around
15–25% of university students suffer from some type of psychiatric
disorder during their undergraduate courses (Adewuya, Ola,
Aloba, Mapayi, & Oginni, 2006; Eri
c, Radovanovi
c, & Jevremovi
c,
1988; Giglio, 1981; Segal, 1966). Among these, 8–17% suffer from
some type of depressive disorder (Cavestro & Rocha, 2006).
Moreover, high levels of anxiety and stress are widely observed
among undergraduates (Ferraz & Perreira, 2002).
According to Enns, Cox, Sareen, and Freeman (2001); Costa and
Pereira (2005), among university populations, depressive
Porcu et al. (2001) pointed out that these symptoms may not only
be of the student’s own character but may also include coping
with a new place of activities and new social relationships, now
vocational training.
Students’ adaptation to university seems to be closely linked
to the welcome and support received, both from teachers and
from fellow students, and the support provided by their own fam-
ilies. Lack of these support elements may cause emotional with-
drawal and mental distress among students (Costa & Leal, 2008).
Exposure to a diversity of tasks, including with regard to socio-
professional relationships, may equally lead to difficulties in adapt-
ing to the realities, which is a crucial factor in relation to individu-
als’ mental health (Caires & Almeida, 2003).
The way in which medical professional training is developed
has recently been undergoing some paradigm shifts. Active meth-
odology has been the paradigm of many medical schools, and
among them appears more often the PBL. Unlike receive content
through a teacher in PBL, your learning experience is self-directed.
Students is that they are responsible for organizing the learning,
conducted by a tutor or facilitator at the time they are taken early
to the experience of real situations. For authors like Berbel (1998);
Cyrino and Toralles-Pereira (2004), as a result of this teaching

CONTACT Jos
e Aderval Arag~ao jaafelipe@infonet.com.br Rua Aloisio Campos 500, Bairro Atalaia, Aracaju, Sergipe CEP: 49035-020, Brazil
ß 2017 Informa UK Limited, trading as Taylor & Francis Group
 2 ~ ET AL.
J. A. ARAGAO
method, it is expected good medical skill, more reflective, with
good capacity for action and decision.
Gomes, Brino, Aquilante, and Avo
(2009), highlighted as a dis-
tinctive aspect of PBL, self-directed learning. The authors have
given associated with this fact, the development of skills such as
psychomotor, communication, attitudinal and the constant pursuit
of knowledge. Thus, unlike the traditional method, PBL, can best
stimulate reflexive criticism. For authors such as Teixeira, Dores,
Santos, Barreto, and Martins (2013), these aspects of the PBL, it is
possible that they are responsible for adapting to the new reality
experienced by the students when they started their medical
course.
The present work was carried out in view of the context
reported by these authors, also showing the interest of better
comparing the PBL with what is known about the traditional
method. The subject was investigated after the graduation of the
first class in PBL, in the state of Sergipe/Brazil, in 2015.
Downloaded by [Australian National University] at 17:40 06 October 2017
Method
This was a cross-sectional study to compare the prevalence of
depression among medical students taught using PBL versus trad-
itional methodologies, which was conducted in the second semes-
ter of 2014. As traditional is understood the teaching
methodology based on the transmission of content by a teacher
and learned through memorisation by routine and not in learning
by doing. The sample used was probabilistic and included the
beginner students (the first, second) and those that precede the
stage (eighth) semesters of the medical courses at two universities
in the state of Sergipe, Brazil. In both universities, in national
selection, 50 students per semester are admitted, for a course full
time during 12 semester. During the course, students perform
procedural reviews and cognitive beyond progression test and the
objective, structured clinical examination (OSCE). Out of the total
of 300 students who were eligible to participate in this survey, 65
were excluded because they did not come on the day when the
questionnaire was going to be applied and 20 refused to
participate.
To screen for symptoms and identify the severity of depression,
Beck’s Depression Inventory (BDI) was used, in its form that has
been translated and validated for use in Portuguese (Gorenstein &
Andrade, 1998). The BDI has 21 items and investigates symptoms
and attitudes at four degrees of intensity, with emphasis on cog-
nitive, vegetative, motor and mood symptoms. To evaluate the
results from the BDI, the following parameters indicating the
degree of depression were used: 0–9 absence of depression;
10–18 mild depression; 19–29 moderate depression; and 30–63
severe depression. In addition to this, the students also answered
the following two questions: (1) Are the expectations that you
had before starting the medical course being fulfilled? (2) Are you
satisfied with the activities developed within the medical course?
The variables were tested regarding normal distribution of the
data, by means of the Shapiro–Wilk test. For analyses making
comparisons between groups, the independent Student’s t-test or
the Mann–Whitney U-test was applied. The prevalence of depres-
sion was calculated as the number of individuals with this out-
come divided by the total number in the sample from each
course, with the respective 95% confidence intervals. Associations
between categorical variables were investigated using the chi-
square test (x2) with Yates correction or using Fisher’s exact test.
The statistical significance level stipulated was 5% (p
.05). For all
the analyses, the Statistical Package for the Social Sciences soft-
ware (SPSS 15.0, Aracaju, Brazil) was used. This study was
approved by the Research Ethics Committee of the Federal
University of Sergipe, under protocol CAAE 35503314.8.0000.5546.
All the subjects participating in this study were informed about
the research objectives and signed an informed consent
statement.
Results
The median age among the students was 21 years (1st
quartile ¼ 19; 3rd quartile ¼ 24). Among the students taught using
traditional methods, the median was 21 years (1st quartile ¼ 19;
3rd quartile ¼ 24), and among those taught using PBL, it was 21.5
years (1st quartile ¼ 19; 3rd quartile ¼ 24). The difference in the
median between the two groups was not statistically significant
(p ¼ .631).
Beck’s Depression Inventory (BDI) was filled out by 215 stu-
dents: 52.1% (112) males and 47.9% (103) females, among whom
51.6% (111) were on courses following PBL methodology and
48.4% (104) following traditional teaching methods.
Table 1 presents the findings regarding the prevalence of
depression among the students according to the teaching
method: among those following PBL, it was 29.73% with 95% CI
[22.02; 38.79]; and among those following traditional methods, it
was 22.12% with 95% CI [15.21; 31].
Regarding the scores obtained according to the teaching
methodology, the median was seven points for the traditional
method (1st quartile ¼ 4; 3rd quartile ¼ 11) and eight points for
PBL (1st quartile ¼ 4; 3rd quartile ¼ 13). There was no statistically
significant difference between the two groups (p ¼ .277).
According to sex, the prevalence of depression among the
medical students following the PBL method was 32.8% with 95%
CI [22.57; 45] for females and 25.5% with 95% CI [15.25; 39.51] for
males. These findings were not statistically significant (p ¼ .223).
Among the students following traditional methods, the prevalence
of depression according to sex was 23.1% with 95% CI [12.65;
38.34] for females and 21.5% with 95% [13.29; 33.97] for males.
These findings too were not statistically significant (p ¼ .964)
(Table 2).
To analyse the possible association between depression and
the students’ ages, the result from calculating their median age
was used, that is, a cut-off point of 21 years was used. Thus, the
students were categorized as up to 21 years of age or over 21
years of age. Table 3 shows that the prevalence of depression
among the students following the PBL method who were up to
21 years of age was 29.4% with 95% CI [18.71; 43], and for those
over 21 years of age, it was 32.1% with 95% CI [21.09; 45.48].
These findings were not statistically significant (p ¼ .742). Among
the students following traditional methods who were up to 21
years of age, the prevalence of depression was 16.7% with 95% CI
[9.02; 28.74] and for those over 21 years of age, it was 30.1% with
Table 1. Prevalence of depressive symptoms among students according to the
teaching method used.
Teaching method
PBL Traditional
Symptoms n (%) n (%) p
Without depression 78 (70.3) 81 (77.9)
Mild depression 24 (21.6) 17 (16.3) .19
Moderate depression 8 (7.2) 6 (5.8)
Severe depression 1 (0.9) –
Values are expressed as absolute and relative frequencies (chi-square association
test).
 INTERNATIONAL JOURNAL OF PSYCHIATRY IN CLINICAL PRACTICE 3

95% CI [16.57; 41]. These findings too were not statistically signifi-
cant (p ¼ .322).
The prevalence of depression among the students following
the PBL method according to the semester of the medical course
that they were in was distributed as follows: 34.4% with 95% CI
[20.41; 51.69] in the first semester; 37.2% with 95% CI [23.17;
53.66] in the second semester; and 20.5% with 95% CI [11.15;
34.50] in the eighth semester. These findings were not statistically
significant (p ¼ .182). Among the students following traditional
methods, the prevalence of depression was: 18.2% with 95% CI
[8.61; 34.39] in the first semester; 6.1% with 95% CI [1.68; 19.61] in
the second semester; and 39.5% with 95% CI [25.60; 55.28] in the
eighth period. These findings were statistically significant
(p ¼ .016) (Table 4).
The students were asked whether the expectations that they
had before starting the medical course were being fulfilled, and
78.6% (180) of them gave positive replies: 55% (99) were following
the PBL method and 45% (81), traditional methods. Likewise,
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seemed to be less satisfied with their course, with lower rates of
fulfilment of the expectations that they had before starting the
course. However, they had a low prevalence of depression com-
pared to those who attended the PBL teaching methodology.
Discussion
Overall, among the 215 students evaluated, 56 (26.04%) presented
some degree of depression (mild, moderate or severe). This pro-
portion was higher than what was reported by several authors
who studied the overall prevalence of psychiatric disorders among
university students, which ranged from 8% to 17% (Adewuya
et al., 2006; Eri
c et al., 1988; Lindeman et al., 1996; Neves &
Dalgalarrondo, 2007). This higher rate may have been related to
the fact that 43.2% (93) of the medical students had family histor-
ies of depression and/or other mood disorders. However, in stud-
ies on general university populations by Amaral et al. (2007),
Costa and Pereira (2005), Enns et al. (2001), Rezende, Abr~ao,

70.2% (160) said that they were satisfied with the activities devel- Coelho, and Passos (2008), Sakae, Pad~ao, and Jornada (2010) and
oped within the medical course, of whom 58.8% (94) were follow- Paula et al. (2014), the prevalence of depressive symptoms was
ing the PBL method and 41.3% (66), traditional methods (Table 5). found to be higher among medical students. Helmers et al. high-
The findings from the present study showed that although the lighted that the high levels of depression among medical students
medical students following traditional teaching methodology could not be considered to be caused only by stress, given that
Table 2. Prevalence of depressive symptoms among students according to their sex and the teaching method used.
Teaching method
PBL Traditional
Sex Sex
Female Male Female Male
Depressive symptoms n (%) n (%) p n (%) n (%) p
Without depression 43 (67.2) 35 (74.5) 30 (76.9) 51 (78.5)
Mild depression 14 (21.9) 10 (21.3) .22 7 (18) 10 (15.4) .96
Moderate depression 6 (9.4) 2 (4.2) 2 (5.1) 4 (6.1)
Severe depression 1 (1.5) – – –

Values are expressed as absolute and relative frequencies (chi-square association test).

Table 3. Prevalence of depressive symptoms among students according to their age group and the teaching method used.
Teaching method
PBL Traditional
Age group Age group

21 years >21 years
21 years >21 years
Depressive symptoms n (%) n (%) p n (%) n (%) p
Without depression 36 (65.4) 36 (64.3) 45 (81.8) 25 (64.1)
Mild depression 15 (27.3) 16 (28.6) .74 7 (12.7) 11 (28.2) .32
Moderate depression 4 (7.3) 3 (5.4) 3 (5.5) 3 (7.7)
Severe depression – 1 (1.8) – –
Values are expressed as absolute and relative frequencies (chi-square association test).

Table 4. Prevalence of depressive symptoms among students according to their semester and the teaching method used.
Teaching method
PBL Traditional
Semester Semester
1st 2nd 8th 1st 2nd 8th
Depressive symptoms n (%) n (%) n (%) p n (%) n (%) n (%) p
Without depression 21 (65.6) 22 (62.8) 35(79.5) 27 (81.8) 31 (93.9) 23 (60.5)
Mild depression 7 (21.9) 10 (28.6) 7 (15.9) .18 4 (12.1) 2 (6.1) 11 (29) .016
Moderate depression 4 (12.5) 3 (8.6) 1 (2.3) 2 (6.1) – 4 (10.5)
Severe depression – – 1 (2.3) – – –
Values are expressed as absolute and relative frequencies (chi-square association test).
Statistical significance (p
.05).
 4 ~ ET AL.
J. A. ARAGAO
Table 5. Expectations regarding the medical course and satisfaction with the activities among the medical students, according to the teaching method.
Questions
Are the expectations that you had before starting the medical course being fulfilled?
Are you satisfied with the activities developed within the medical course?
Statistical significance (p
.05).
the rates were similar in the two groups that they studied.
Depression may have other causative factors such family antece-
dents, genetic inheritance, the environment in which students live
(such as university dormitories), adverse events of life, losses, love
life problems, gender identity and not having a circle of friends.
Symptoms of mild, moderate and severe depression were more
prevalent (29.73%) among the students who were following the
PBL method. Lewis et al. (2009) attributed such findings to the
Downloaded by [Australian National University] at 17:40 06 October 2017
change from the methodology of traditional teaching (expositive
classes) to active methodology (in which students actively seek
knowledge). Moreira and Manfroi (2011) and Smolka, Gomes, and
Siqueira-Batista (2014) provided explanations of the PBL method-
ology and emphasized that because it is centred on the student,
it consequently demands greater personal commitment. Thus,
according to Canale and Furlan (2006), complaints such as des-
pondency, irritable moods and loss of capacity to plan (some of
which are inherent to symptoms of depression) become more
frequent.
In the present study, the prevalence of depression among
female medical students was 29.12% and among males, 23.21%.
This difference was not statistically significant. However, these lev-
els were higher than what Dell’Aglio and Hutz (Dell’Aglio & Hutz,
2004) found in a general population: 10–25% among women and
5–12% among men).
The presence of depressive symptoms among medical students
according to their age group was difficult to discuss, given that
these cut-off points seem not to have been used in other studies
(Amaral et al., 2007; Paula et al., 2014; Sakae et al., 2010). Authors
such as Gotlib (1984) and Gorenstein and Andrade (1998) reported
that there was no difference regarding the age at which depres-
sion appeared. In the present study, independent of age group,
occurrences of symptoms of depression showed a tendency to be
greater among students following PBL.
Symptoms of depression were most prevalent among students
following the PBL method who were in their first semester
(34.4%) and second semester (37.2%), while they were most
prevalent among students following traditional methods who
were in their eighth semester (39.5%). This may be a consequence
of the methodology PBL methodology, in which students are
exposed early, through the various scenarios of development of
learning to the reality of situations. According to Meleiro (1998)
and Rezende et al. (2008), this higher frequency of depression in
the eighth semester of traditional medical courses may be con-
nected to the reality of the hospital environment, unlike for the
students of the same semester who attended the PBL. According
to Melo-Carrillo, Oudenhove, and Lopez-Avila (2012) and Andrade
et al. (2014), these findings and assertions show that mental dis-
tress occurs at the time when students start to have more inten-
sive contact with hospital wards, when clinical training becomes
an important source of stress. According to Costa et al. (2012), the
imminence of entering internship may also be presented as a
major academic requirement, thereby leading to increased
PBL Traditional
Yes No Yes No
n (%) n (%) n (%) n (%) p
99 (89.2) 12 (10.8) 81 (77.9) 23(22.1) .044
94 (84.7) 17 (15.3) 66 (63.5) 38 (36.5) .001
demands on individuals and thus worsening the depressive
symptoms.
Although there was higher frequency of depression (29.7%)
among medical students who were following the PBL method,
they reported having high rates of satisfaction and fulfilment of
expectations in relation to the activities that they had developed
during the course. Similar data were reported by Filho and Ribeiro
(2009), who accepted that PBL had brought in a new approach in
which analysis of a single situation from different angles was
stimulated and problem-solving skills were developed. In these
authors’ view, this was a highlight of this method and a point of
satisfaction among the students. According to Granado, Santos,
Almeida, Soares, and Guisande (2005) and Santos, Polydoro,
Scortegagna, and Linden (2013) even though there was higher fre-
quency of depression among medical students who followed PBL
methodology, the greater satisfaction among these students start-
ing from the first year of their course gave rise to increasing levels
of perseverance and created the conditions for professionals with
a better sense of security who were better qualified, to emerge
over the duration of the academic course.
Conclusions
The prevalence of depressive symptoms was very high among the
medical students who were following both PBL and traditional
methodologies. However, the prevalence was higher among the
PBL students, who were also shown to have greater satisfaction
with the activities developed during the medicine course and to
have attained fulfilment of the expectations that they had before
starting the course.
Acknowlegdements
None.
Disclosure statement
No potential conflict of interest was reported by the authors.
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