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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 37  |  Issue : 2  |  Page : 183-190

Depression among medical students of India: Meta-analysis of published research studies using screening instruments


1 Department of Community Medicine, North Delhi Municipal Corporation Medical College and Hindu Rao Hospital, New Delhi, India
2 Amity Institute of Public Health, Noida, Uttar Pradesh, India

Date of Submission19-May-2020
Date of Decision04-Jun-2020
Date of Acceptance10-Jun-2020
Date of Web Publication30-Jun-2021

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_119_20

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  Abstract 


Objectives and Background: To determine the pooled prevalence of depression among medical students of India by undertaking meta-analysis of published original research studies Materials and Methods: Systematic search was undertaken using PubMed and Google Scholar databases for freely available original articles published between 2014 and 2018 on the subject depression among Indian medical (MBBS) undergraduate students using PRISMA guidelines. Results: A total of 28 original research articles were identified involving 7046 medical students from different medical colleges of India. The median number of students was 284.5 (range, 86–444). All the original research articles had used standardized and validated global screening instruments for identifying depression, and none was based on clinical diagnosis. Meta-analysis of pooled prevalence estimate of depression among medical students in India by random-effects model was 40% (confidence interval [CI]: 32%–47%). Girls had a slightly higher risk of depression than boys (odds ratio = 1.06; 95% CI: 0.81–1.38). There were a total of 16 (57.1%) research articles with the presence of psychiatrist as a co-author and had a pooled prevalence of 39% (95% CI: 29%–49%). The remaining 12 studies without psychiatrist as co-author also reported a nearly similar finding, with prevalence of 44% (95% CI: 33%–54%). On subgroup analysis, it was revealed that the pooled prevalence of depression was 37.9% (95% CI: 22–55), 45% (95% CI: 42–52), and 34% (95% CI: 24–50) in research articles using study instruments Beck Depression Inventory, Depression Anxiety Stress Scale, and other miscellaneous screening instruments, respectively. Conclusion: Within study limitations, the high prevalence of depression was noted among medical students of India and the situation warrants comprehensive management by stakeholders.

Keywords: Academics, Beck Depression Inventory, Depression Anxiety Stress Scale, MBBS student, mental health, Primary Health Questionnaire, screening


How to cite this article:
Dwivedi N, Sachdeva S, Taneja N. Depression among medical students of India: Meta-analysis of published research studies using screening instruments. Indian J Soc Psychiatry 2021;37:183-90

How to cite this URL:
Dwivedi N, Sachdeva S, Taneja N. Depression among medical students of India: Meta-analysis of published research studies using screening instruments. Indian J Soc Psychiatry [serial online] 2021 [cited 2021 Nov 28];37:183-90. Available from: https://www.indjsp.org/text.asp?2021/37/2/183/320215




  Introduction Top


Depressive disorders are characterized by sadness, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, feelings of tiredness, and poor concentration. Depression can be long-lasting or recurrent, mild or severe, substantially impairing an individual's ability to function at work or school or cope with daily life (WHO). At its most severe form, depression can lead to suicide. Globally, the total number of people living with depression was estimated to exceed 300 million in 2015 equivalent to 4.4% of world population. The prevalence rate of depression varies from 3.6% in the Western Pacific Region, 4.4% (European region), 4.5% (South-East Asia), 4.5% (Eastern Mediterranean), 4.9% (American region), to 5.4% in the African Region. Depression is more common among females (5.1%) than males (3.6%).[1] In India, it is estimated that the prevalence of depressive disorder is 4.5% among total population (WHO).

Mental health of a medical student could be affected due to long study and working hours, extensive course content, examinations, peer competition, uninspiring environments, sleep deprivation, and loneliness including other factors interfering in everyday personal, social, and family life.[2],[3],[4],[5] Medical education is a full-time commitment involving academic tasks, activities, social conduct, support, and care to patients. Medical education is generally perceived as being stressful, and a significant degree of psychological morbidity has been reported among medical students across the globe including India leading to decreased productivity and absenteeism.[6],[7]

Globally, it has been demonstrated that 25%–90% of medical students are stressed, which is an important determinant of depression and anxiety.[8],[9] A systematic review of 183 studies from 43 countries revealed the crude prevalence of depression among medical students to be around 27.2% (95% confidence interval [CI]: 24.7%–29.9%), with 11.1% prevalence of suicidal ideation.[10] The authors found only one systematic study carried out till date[11] in India for the period 1970–2015; therefore, the present study was undertaken with an objective to determine the pooled prevalence of depression among Indian medical undergraduate students based on published research article for a close interval of 2014–2018 with minimum changes/variation in the external environment.


  Materials and Methods Top


Eligibility criteria

We selected Indian original research studies on depression among Indian medical (MBBS) undergraduate students and published within the period 2014–2018. The primary outcome of the study was estimation of pooled prevalence of depression among medical students of India.

Data sources and search strategy

Systematic search was undertaken using PubMed and Google Scholar databases for freely available articles published in English language during 2014–2018 on the prevalence of depression among Indian medical students. The keywords used for search strategy included (medical students) OR (medical undergraduates) OR (MBBS students) OR (university health students) AND (depression) AND (India OR Indian). Using this strategy, we were able to identify 28 relevant original research articles reporting depression among medical students of India. All the original published studies had a cross-sectional research design. Out of these 28 articles, six studies were published during the reference year 2014, seven in 2015, seven in 2016, six in 2017, and two in 2018.

Data extraction

Two authors ND and SS were independently involved in data collection using PRISMA guidelines, and NJ acted as a moderator after standardization process followed by consensus decision [Figure 1]. The following information was extracted from each article: place of study in India, year of publication, total number of medical students, number of female, number of male, age (mean) of student, prevalence of depression reported in the study, prevalence of depression among male students, prevalence of depression among female students, study instrument used, etc., Data related to any other comorbid mental condition such as stress or anxiety were not recorded.
Figure 1: Search strategy utilized for identifying original research articles with depression among Indian medical students

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Quality assessment

The Newcastle–Ottawa Scale was adapted to assess the quality of cross-sectional studies.[12] The scale classifies the articles into three categories based on scores: (i) selection criteria (score 0–5), (ii) comparability criteria (score 0–2), and (iii) outcome criteria (score 0–3); thus, the total score ranged between 0 and 10. The selection category consisted of parameters such as representativeness of the sample and adequacy of the sample size; comparability category examines whether the individuals in different outcome groups are comparable based on analysis, whether confounding factors were controlled or not; outcome category included whether data on outcome were collected through records or by self-reporting. It also includes whether statistical tests used to analyze data were clearly described and whether tests were appropriate or not. On the basis of scoring pattern, studies were grouped at low risk of bias (≥5 points) or high risk of bias (<5 points).

Publication bias

The publication bias was assessed with Egger test and used the funnel plot to graphically represent the bias.[13],[14],[15],[16] Possible sources of asymmetry in funnel plots include reporting bias, poor methodological quality, true heterogeneity, fraud, artifact, and chance.

Data management and statistical analysis

Meta-analysis of the reported prevalence of depression among medical students was undertaken upon selected published studies. Heterogeneity between studies was quantified by the I2 statistic. We considered I2 > 50% to represent substantial heterogeneity. In our analysis, we found a high (>97%) degree of heterogeneity among the studies, and thus, we have used random-effects model to derive the pooled estimate for depression. The final estimates of prevalence were reported as percentage with 95% CI.

We also did separate subgroup analysis for the following factors: study instrument used, quality score of the articles, and psychiatrist as a co-author. We studied within-group heterogeneity, i.e., the studies using the same instruments and falling in the same quality score range, and between-group heterogeneity, i.e., heterogeneity between studies using different instruments and falling under different quality score range. We also studied the effect of depression on gender.

Data handling and statistical analyses were performed using R software, version 3.2.3 (R Foundation for Statistical Computing). Statistical tests were two-sided with significance threshold of P < 0.05.


  Results Top


Study characteristics

The present meta-analysis considered 28 original studies involving a total of 7046 medical students from different medical colleges of India.[6],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43] A total of 3170 females and 3189 male medical students were considered, while three studies did not mention gender details separately and hence were excluded. The median number of students was 284.5 (range, 86–444). Among all the studies, around 3003 (42.6%) medical students were reported to be depressed. In 57.1% of research studies, at least one of the co-authors was psychiatrist. All the research articles had used standard screening instruments for identifying depression, and none of them was based on clinical diagnosis. [Table 1] depicts the list of research studies included in the present meta-analysis along with selected information.
Table 1: Characteristics of studies reporting prevalence of depression among medical students of India, 2014 (January)-2018 (July)

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Pooled prevalence of depression among medical students

Meta-analytic pool prevalence estimates of depression by both fixed- and random-effects models are shown in [Figure 2]. The pooled prevalence by fixed- and random-effects models was 42% with CI (41%–43%) and 40% with CI (32%–47%), respectively. There was significant evidence of between studies' heterogeneity (Q = 1079.82 with P < 0.001). As the degree of heterogeneity among studies was high (>97%), we used only random-effects model for further subgroup analysis on following factors: quality scores of the articles, study instrument, and the presence of psychiatrist as a co-author. Based on available information, female students (odds ratio: 1.06 [95% CI: 0.81–1.38]) had slightly higher risk of being depressed than males.
Figure 2: Forest plot depicting prevalence of depression among medical students

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Prevalence of depression by quality scores of the articles

We grouped the research studies into two broad categories on quality scores (range, 0–10): low (<5) and high (≥5) quality scores. There were three studies with low and rest with high quality score. Studies with low quality (score <5) had a pooled prevalence of depression as 34% (95% CI: 25–49) and those with high quality (score ≥5) had a prevalence of 42% (95% CI: 33–50).

There was significant evidence of heterogeneity within studies. For studies having low quality (score <5), Q = 32.90 with P < 0.001, the heterogeneity was quantified using τ2 = 1.729, I2 = 96.96% with 95% CI: 88.7%–98.7%. For studies having quality score ≥5, Q = 763.19 with P < 0.001, the heterogeneity was quantified by τ2 = 0.725, I2 = 97.49% with 95% CI: 94.2%–98.2%. However, there was no significant heterogeneity between studies with Q = 0.617, P = 0.397.

Prevalence of depression by study instrument

All the published research studies had used standard study instrument for determining the prevalence of depression among medical students. We grouped the research articles into three broad categories based on the type of study instrument used: (1) Beck Depression Inventory (BDI); (2) Depression Anxiety Stress Scale (DASS), and (3) others (Quick Inventory of Depressive Symptomatology [QIDS], Hamilton Depression Rating Scale, Automatic Thoughts Questionnaire and Insomnia, ZSRDS, TDEQ, QIDS-Self-Report, and vignette) irrespective of cutoff criterion. The pooled prevalence of depression among medical students was found to be 37.9% (95% CI: 22–55), 45% (95% CI: 42–52), and 34% (95% CI: 24–50) in research articles using study instruments BDI, DASS, and other miscellaneous instruments, respectively. Again, there was statistically significant evidence of heterogeneity within studies (P < 0.001) but no significant heterogeneity between studies of these broad groups (P = 0.30).

Prevalence of depression in studies with or without psychiatrist as a co-author

The studies were divided into two broad groups based on the presence of psychiatrist as one of the co-authors. There were a total of 16 (57.1%) research articles with the presence of psychiatrist as a co-author and had a pooled prevalence of 39% (95% CI: 29%–49%). The remaining 12 studies without psychiatrist as a co-author had a pooled prevalence of 44% (95% CI: 33%–54%) depression among medical students.

There was significant evidence of heterogeneity within studies with psychiatrist as a co-author (Q = 346.62 with P < 0.001). For studies without psychiatrist as an author, Q = 435.38 with P < 0.001, there was significant evidence of heterogeneity also found between studies of these groups as Q = 799.76, P < 0.001.


  Discussion Top


The present meta-analysis considered 28 original studies involving a total of 7046 medical students from different medical colleges of India. The pooled prevalence of depression based on standard screening instruments among medical students of India was found to be 40% with CI (32%–47%). None of the original studies reviewed were based on clinical diagnosis of depression but reported the prevalence on standard screening instruments.

The listed studies[6],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43] were conducted in diverse regions of India such as Karnataka (Bagalkot, Bengaluru (2), Dakshin Kannada, Mangalore, Mysore, and Tumkur), Gujarat (Jamnagar, Karamsad, and Vadodara), Uttar Pradesh (Jhansi), West Bengal (Kolkata), Maharashtra (Mumbai), Odisha (Bhubaneswar), Rajasthan (Jaipur and Jodhpur), Madhya Pradesh (Bhopal), Andhra Pradesh (Guntur and Vizianagaram), Kerala (Kolenchery, Meppadi, and Trivandrum), Telangana (Fasalwadi), Himachal Pradesh (Shimla), Jammu and Kashmir (Srinagar), Goa, Puducherry, and New Delhi giving a fair case-scenario of the entire country.

The only other systematic study carried out in the country on the same objective reviewed studies published during 1970–2015 (n = 16 with total number of medical students as 3882) and reported a similar pooled prevalence of depression as 39.2% (95% CI: 29.0%–49.5%).[11] The sample sizes of the studies varied from 90 to 421. The range of prevalence of depression in these studies varied from 8.7% to 71.3%. The most common instrument used was BDI, followed by other rating scales including Primary Health Questionnaire-9, DASS, and QIDS. The study finding was similar with females reporting slightly higher prevalence of depression than male students.

The strength of our analysis includes review of close interval (2014–2018) of original published studies with a total of 7046 medical students and minimum variation/changes in the external environment, thus giving a robust figure of situation analysis. Few limitations include high heterogeneity (I2 = 97%) between studies as reflected by asymmetrical funnel plot [Figure 3] and Egger test (P = 0.009) suggestive of quality/methodological issues or publication bias. The severity of depression was not reported in original studies and hence not reflected in our review. Some of the studies that were not freely available in public domain were not covered and might influence the outcome. All the original research articles have used standard screening instrument and prescribed cutoff criteria for reporting depression, and none of them was based on clinical diagnosis. Hence, the real differences between the two concepts have to be kept in mind before making any generalized assumptions. Therefore, a possibility of overestimation (false positive) of depression using screening instruments cannot be denied.
Figure 3: Funnel plot depicting the publication bias in the meta-analysis

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All the medical colleges in country technically operate under standards prescribed by regulatory body (Medical Council of India); still, difference may exist between the colleges depending on ownership of college (government or private/trust), patient load, geographical location, personality type of students, socio-economic-cultural background, infrastructure and amenities available to students, extracurricular activities, teaching/social/personal/cultural/hostel/mess environment prevailing in these institutions, etc., that may have a diverse influence on the minds of medical students.

The content of MBBS subject in medical colleges of India is based on evidence-based global best practices taught in English language, with the course duration of four and half years followed by 1-year mandatory 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 students to keep record of daily activity/learning in a logbook followed by regular formative and summative evaluation.[44],[45] 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 a developed country have roots in this great nation.[46],[47] It could be partly attributed to screening of best brain by competitive entrance examination and rigor of professional training in medical colleges of India. However, during this period of rigorous training, some students suffer from mental morbidity and develop other psychological problems as well leading to substance abuse practices.

A longitudinal study has shown that the prevalence of depressive symptoms among students before medical training was <2% which is similar to general population; later, the prevalence escalated up to 30% at the end of the 1st-year medical training.[48] Depression in medical students is a global phenomenon, often underrecognized and undertreated with stigma surrounding mental health issues that often deter medical students from seeking professional help in spite of readily available service at close quarter.[49] Some of the statistically significant (P < 0.05) determinants resulting in higher proportion of depression among medical students were found to be female gender, geographical location of medical college in cities, the presence of mental illness in family, poor relationship with family, dissatisfaction with body image, global dissatisfaction in life, high aspirations, inability to cope with medical syllabus, newly entrant students in medical college, etc.[6],[50],[51]

The quality of learning, skill acquisition, and lifetime outcome of such depressed students in professional, personal, social life, and poor productivity can be easily gauged. Evidences exist in literature that have proved that stress management interventions (seminar/training course/counseling-mindfulness meditation/somatic relaxation/self-development/discussion group/well-being workshop/self-hypnosis training) were positively associated with moderate effects on medical student psychological health (general well-being, depression, anxiety, or stress) compared with no intervention. Brief to medium-duration intervention demonstrated significantly larger effect than long-duration interventions.[52] Some of the medical colleges in India have institutionalized these preventive measures.


  Conclusion Top


Our meta-analysis based on original research articles that have used screening tools revealed a significant burden of depression (40%) among medical students of India. Situation requires comprehensive management by stakeholders.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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