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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 34  |  Issue : 2  |  Page : 157-162

Assessment of depression, anxiety, and stress among medical students enrolled in a medical college of New Delhi, India


Department of Community Medicine, North DMC Medical College and Hindu Rao Hospital, New Delhi, India

Date of Web Publication29-Jun-2018

Correspondence Address:
Dr. Sandeep Sachdeva
Department of Community Medicine, North Delhi Municipal Corporation Medical College and Hindu Rao Hospital, New Delhi - 110 007
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_114_17

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  Abstract 


Objective: The objective of this study was to determine the prevalence of depression, anxiety, and stress among medical students. Materials and Methods: Students underwent face-to-face interview using predesigned, pretested, anonymous interview schedule using standardized survey instrument and Depression Anxiety Stress Scale 21 item. Information was also collected on sociodemographic, academic profile, and personal characteristics of students. All the students enrolled in the medical college from first to final year were invited to participate, and the study was conducted during mid-semester to ensure that there was no university examination or college festival/event. Results: A total of 187 students participated in the study giving a response rate of 94%. The participants were predominantly male (66%) and majority (65.8%) residing in hostel. It was noted that 7.5% reported parental conflict; 15.0% were “always” fearful about future life; 21.9% had poor relationship with family members; 22.5% were not satisfied with their body image; and 18.7% were globally dissatisfied. It was observed that 60 (32.0%), 75 (40.1%), and 82 (43.8%) students were affected by symptoms suggestive of depression, anxiety, and stress, respectively. On bivariate analysis, higher proportion of students with anxiety had a history of some medical condition (P < 0.05). Similarly, family history of chronic noncommunicable disorder was significantly (P < 0.05) associated with stress only while students with family history of mental illness had a higher proportion of depression (P < 0.05) only. It was also found that dissatisfaction with body image and global dissatisfaction with life was statistically (P < 0.05) associated with depression and anxiety while fair (poor) relationship with family members was statistically (P < 0.05) associated with depression only. Subjective (self) assessment of ability to cope with medical syllabus was inversely associated (P < 0.01) with ability, i.e., as the student's ability to cope with syllabus increases by one unit, the probability of occurrence of depression and anxiety decreases by 1.29 units and 0.71 units, respectively. Conclusion: It is noted that emotional distress is common among medical students, and there is an urgent need for attention, support, and personalized counseling.

Keywords: Alcohol, behavior change communication, body image, counseling, family relationship, MBBS student, mental health, professional satisfaction, screening program, smoking, social activity


How to cite this article:
Taneja N, Sachdeva S, Dwivedi N. Assessment of depression, anxiety, and stress among medical students enrolled in a medical college of New Delhi, India. Indian J Soc Psychiatry 2018;34:157-62

How to cite this URL:
Taneja N, Sachdeva S, Dwivedi N. Assessment of depression, anxiety, and stress among medical students enrolled in a medical college of New Delhi, India. Indian J Soc Psychiatry [serial online] 2018 [cited 2021 May 18];34:157-62. Available from: https://www.indjsp.org/text.asp?2018/34/2/157/235655




  Introduction Top


Medical education is a full-time commitment and responsibility of students that entails academic tasks, activities, social conduct, support, and care provided to patients. Mental health of a medical student remains affected throughout training due to long study and working hours, extensive course content, examinations, peer competition, un-inspiring environments, sleep deprivation, and loneliness including other factors interfering in everyday personal, social, and family life. Medical education is generally perceived as being stressful and considerable degree of psychological morbidity has been reported among medical students ranging from stress, interpersonal problems, and suicidal ideation to psychiatric disorders.[1],[2],[3],[4] Globally, it has been demonstrated that 25%–90% of medical students are stressed, which is an important determinant of depression and anxiety.[5],[6] A systematic review of 183 studies from 43 countries revealed crude prevalence of depression among medical students to be around 27.2% (95% confidence interval: 24.7%–29.9%) with 11.1% prevalence of suicidal ideation.[7] On the contrary, a recent large sample survey in southern part of India reported an overall prevalence of depression of 15.9% among general population.[8]

Students with dysfunctional emotional state need serious attention and management otherwise inability to cope successfully may lead to adverse consequences at both personal and professional levels.[9] The demand for curbing mental health conditions, especially depression, is gaining momentum across the world since the last couple of decades.[10] It is no surprise that mental health of medical students in India as an area of research domain has attracted the second highest attention of the faculty in medical colleges of country after medical education, learning process, and evaluation.[11] With this background, a study was undertaken to assess the prevalence of depression, anxiety, and stress among medical students enrolled in a government medical college of New Delhi, India.


  Materials and Methods Top


The study population included all the medical students enrolled in a government medical college from first to final year. Students underwent face-to-face interview using predesigned, pretested, anonymous interview schedule after obtaining institutional ethical clearance and informed consent of the students. They were informed about the anonymous and voluntary nature of participation in the study without any undue fear, stigma, or adverse documentation and were contacted during their free time. The study was conducted during September 2017 to ensure that the students were not having any university examinations or college festival/event.

A previously validated and standardized survey instrument, Depression Anxiety Stress Scale (DASS 21), was used to collect information on depression, anxiety, and stress.[12],[13] Additional information was also collected on sociodemographic, academic profile, and personal characteristics of students. Subjective (self) assessment of ability to cope with syllabus and academic performance on a scale of 1–10 points, satisfaction with body image, admission in current medical college, and global satisfaction with life was also assessed. Self-assessment scale from 1 to 10 points was classified into low (1–4), medium (5–7), and high (8–10) score.

DASS (21 item) is a short scale that allows simultaneous assessment of the three emotional states of depression, anxiety, and stress and each domain contains 7 items, divided into subscales with similar content. The depression scale assesses dysphoria, hopelessness, devaluation of life, self-deprecation, lack of interest/involvement, anhedonia, and inertia. The anxiety scale assesses autonomic arousal, skeletal muscle effects, situational anxiety, and subjective experience of anxious affect. The stress scale is sensitive to levels of chronic nonspecific arousal. It assesses difficulty relaxing, nervous arousal, and being easily upset/agitated, irritable/over-reactive, and impatient.

Respondents were asked to document on a 4-point severity/frequency scales to rate the extent to which they have experienced each state over the past week. The scale is as follows: did not apply to me at all = 0; applied to me to some degree or some of the time = 1; applied to me to a considerable degree or a good part of time = 2; and applied to me very much or most of the time = 3. Scores for depression, anxiety and stress are calculated by summing the scores for the relevant items and analyzed as per guidelines. The tool is easy to apply in both clinical and nonclinical settings and suitable for use in different age groups including medical students.

The data were analyzed using statistical software, SPSS (ver. 20.0) (IBM Inc, Armonk, New York, USA). Descriptive statistics and bivariate and regression analysis were carried out to find association and correlation and considered significant at P < 0.05. The internal consistency, i.e., Cronbach's alpha value was 0.87 that was suggestive of high reliability.


  Results Top


A total of 187 students participated in the study giving a response rate of 94%. The profile of the study sample was predominantly male (66%); hosteller (65.8%) with 63.3% of students having one sibling. Nearly 24.1% and 34.6% of students reported having ever smoked or consumed alcohol, respectively. The overall mean age of students was 21.54 (standard deviation = 1.98) years. [Table 1] depicts sociodemographic profile of study participants. It was also found that 31.6% had a family history of chronic noncommunicable disease; 11.2% further mentioned that there was a family history of chronic mental illness while 25.7% of students had suffered with some medical conditions such as typhoid, malaria, pneumonia, and hospitalization due to injury in the past (not shown in table).
Table 1: Sociodemographic profile of study participants (n=187)

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It was found that 60 (32.0%), 75 (40.1%), and 82 (43.8%) medical students were affected by symptoms suggestive of depression, anxiety, and stress, respectively. Details are shown in [Figure 1]. Some students were affected by >1 emotional state. It was observed on bivariate analysis that higher proportion of students with anxiety had a history of some medical condition and this was found to be statistically significant (P< 0.05). Similarly, family history of chronic noncommunicable disorder was significantly (P< 0.05) associated with stress and family history of mental illness with depression only. History of smoking, alcohol intake, and enlisted other social factors had no statistical association with any of the emotional state (not shown in table).
Figure 1: Percentage of medical students affected by the emotional states

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[Table 2] shows association of academic variables of students with depression, anxiety, and stress, and it was found that enrollment batch and ability to cope with syllabus were statistically associated with depression, anxiety, and stress (P< 0.05). Higher proportion of all the three emotional distress states was found in the 1st-year students in comparison to senior students (P< 0.05).
Table 2: Academic profile of study participants affected by the psychological state

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[Table 3] depicts additional personal details of medical students affected by emotional state. It was noted that 7.5% reported parental conflict; 15.0% were “always” fearful about future life; 21.9% had poor relationship with family members; 22.5% were unsatisfied with their body image; and 18.7% were globally dissatisfied. It was found that satisfaction with body image and global satisfaction with life was statistically (P< 0.05) associated with depression and anxiety while relationship with family members was statistically (P< 0.05) associated with depression only. Higher proportion of student with depression had fair (poor) relationship with their respective families.
Table 3: Personal profile of study participants affected by emotional state

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Subjective (self) assessment of ability to cope with medical syllabus was inversely but statistically associated (P< 0.01) with depression and anxiety, i.e., as the ability to cope with syllabus increases, the probability of occurrence of depression and anxiety decreases. As shown in [Table 4], one unit improvement in ability to cope with syllabus results in reduction of 1.29 units in depression and 0.71 units in anxiety.
Table 4: Ordinal regression analysis of association of depression, anxiety, and stress with sociodemographic, academic, and personal profile of medical students

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We further studied the correlation between depression, anxiety, and stress and it was found that they were highly correlated with each other. The correlation coefficient value between depression and anxiety was 0.71, depression and stress was 0.73, and anxiety and stress was 0.78.


  Discussion Top


This descriptive study using DASS-21 scale was suggestive of high prevalence of depression (32.1%), anxiety (40.1%), and stress (43.8%) among medical students enrolled in a government medical college of metropolitan city, New Delhi, India. The predictors such as low ability to cope with syllabus and newly entrant students were significantly (P< 0.05) associated with the emotional distress. This study also reported protective factors such as strong relationship with family members, negative history of medical condition, satisfaction with body image, and global satisfaction with life. Our study was held in the mid-semester, to ensure that the students were not under the influence of any college event or examination. However, a recent large sample survey in southern part of India reported an overall prevalence of depression of 15.9% among general population.[8]

In a similar study from Brazil using DASS scale, 34.6%, 37.2%, and 47.1% of medical students suffered from depression, anxiety, and stress, respectively.[14] A study from Turkey found that 27.1% of students were depressed, 47.1% from anxiety, and 27% students were stressed. In a study from Nepal, depression was reported to be 29.9%, anxiety 41.1%, and stress 27% among medical students.[15] A study based in the United States found 24% of medical students to be depressed while another study from the US reported 12% of medical students to be diagnosed with probable major depression using DSM III criteria.[16] In a study from Egypt, 43.9% of students were suffering from anxiety.[17] Similar alarming statistics have been corroborated by our study also.

Studies conducted in various regions of India reflect diverse situation depending on the use of study instruments. In a study from Bhubaneshwar (Odisha), the prevalence of depression, anxiety, and stress among medical students was 51.3%, 66.9%, and 53%, respectively, using DASS scale.[18] Another study reported that 39.44% of students suffered from depression, 66.05% from anxiety, and 51.37% from stress.[19] A Jodhpur (Rajasthan)-based study found that 57.98% of students depressed and 47.41% suffered from anxiety.[20] Another Delhi-based study found the overall prevalence of provisionally diagnosed depressive and major depressive disorders among medical students to be 21.5% and 7.6%, respectively.[21] On the contrary, some studies conducted two decades ago have found little or no evidence of stress among medical students.[22],[23]

On joining medical college, students embark their professional journey with high expectations and are loaded with lots of new information to be crammed which at times become difficult to process. The students leave the protected, pampered, and very supportive environment of their family and come to stay in hostel under highly competitive environment. This could be contributing to the higher prevalence of depression, anxiety, and stress seen in 1st-year medical students in this study. Similar observation was reported by Aktekin regarding worsening in overall mental health with high level of depression and anxiety among 1st- and 2nd- year medical students.[1] Quince et al. performed a longitudinal study at a UK medical school and found a prevalence of depression ranging from 5.7% to 10.6% among students in the basic years and 2.7% to 8.2% in students from clinical stages of the course.[24] Further, there was no significant difference of emotional state between males and females in our study. In our urban-based study, 22.5% of students were unsatisfied with their body image which is higher than another study conducted at Rohtak, Haryana (13.5%), with a predominantly rural flavor.[25]

The content of MBBS subject in medical colleges of India is based on global best practices, and course duration is of four-and-half years followed by 1-year internship. The students are systematically and in structured way exposed to different subject streams (preclinical, paraclinical, and clinical) through processes prescribed under regulatory body with student to keep record of daily activity/learning in a log book followed by formative and summative evaluation.[26] It is no surprise that India is one of the popular destinations of medical, transplant, reproductive, and health tourism in the world, and a substantial proportion of renowned doctors working in developed country have roots in this great nation.[27],[28] It could be partly attributed to rigor of professional training and the quality of learning environment in medical colleges of India. The development and growth potential of an individual is directly correlated with the depth of knowledge, positive attitude, and diverse skills she/he possesses and demonstrates whether at undergraduate or higher level.[29]

The current number of medical colleges in India stood at 474 with annual MBBS seats of 60,000 plus while the number of postgraduate degree/diploma seats is nearly half of undergraduate seats. Considering the stiff challenge in securing a postgraduate seat in India, a significant proportion of undergraduate students in Delhi (India) are preparing for postgraduate entrance examination starting from the 2nd year onward.[30] It can be though attributed to early start and purposeful planning but also indicating a case scenario of intense peer pressure, uncertain future environment, rising stress, and anxiety.

Medical students under strain are either unaware of their situation or reluctant to seek help. High-risk students found in our study were provided personal and confidential counseling under additional supervision of mental health expert.


  Conclusion Top


Emotional distress is common among medical students, and there is a need for attention, support, and personalized counseling services.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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