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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 9  |  Issue : 1  |  Page : 87-94

A study on depression, anxiety, stress, and life quality among medical aspirants and medical students of Aligarh City in North India


1 MBBS Second Professional Student, Faculty of Medicine, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, India
2 Department of Biochemistry, Faculty of Medicine, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, India

Date of Submission28-Jan-2021
Date of Decision08-Apr-2021
Date of Acceptance16-Apr-2021
Date of Web Publication26-Jun-2021

Correspondence Address:
Dr. Sufia Naseem
Department of Biochemistry, Faculty of Medicine, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_32_21

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  Abstract 


Background and Aim: Rapid intellectual and psychosocial development occurs mainly during young adulthood. Coincidently, decisions regarding collegiate and professions are taken during this period. Thus, adulthood is vulnerable to psychological disorders. Contrary to most other professions, medical education is more likely to affect mental health. The present explicates the prevalence of depression, anxiety, and stress among premedical and medical students of Aligarh city, and various coping mechanisms they adopt to mitigate above symptoms. Assessment on students' quality of life (QOL) has also been made. Materials and Methods: The study sample (220) consisted of 11th and 12th pursuing and 12th passed students preparing for medical entrance examinations and those pursuing the medical course. The study protocol was approved by the Institutional Ethics Committee. The method of online survey was questionnaire through Google forms. Study lasted for 3 months. We used Depression Anxiety Stress Scale and World Health Organization QOL (WHOQOL)-BREF (QOL assessment scale developed by WHO) questionnaires. Results: Our study suggests that levels of extremely severe anxiety (37.7%) and depression (20%) were relatively higher than stress (10.9%) in the respondents. The Pearson's Chi-square alpha and the P value indicated that depression, stress and anxiety were quite gender centric. We also found significantly higher levels of depression, stress, and anxiety in 11th, 12th pursuing, 12th passed students preparing for medical entrance, final professional (Part 2) students, and interns. Furthermore, physical domain of QOL score showed strong negative correlation with depression, stress, and anxiety. Conclusion: The present study found that depression, stress, and anxiety are present among medical as well as premedical students. It is a matter of concern, as the conditions may severely affect the health as well as the performance of students.

Keywords: Anxiety, depression, quality of life, stress


How to cite this article:
Khursheed M, Naseem S. A study on depression, anxiety, stress, and life quality among medical aspirants and medical students of Aligarh City in North India. Arch Med Health Sci 2021;9:87-94

How to cite this URL:
Khursheed M, Naseem S. A study on depression, anxiety, stress, and life quality among medical aspirants and medical students of Aligarh City in North India. Arch Med Health Sci [serial online] 2021 [cited 2021 Nov 30];9:87-94. Available from: https://www.amhsjournal.org/text.asp?2021/9/1/87/319395




  Introduction Top


Young adulthood is the period of rapid intellectual and psychosocial changes in all humans, but it is challenging for the students' because during this time they decide regarding their collegiate and professional career which makes them vulnerable to derangement in mental homeostasis.[1] Thus, it becomes necessary for the students to have good knowledge of mental health problems, their early symptoms, and effective treatment options.[2]

It has been widely held that the study of medicine is one of the most stressful professional choices.[3],[4] Stress experienced by medical students predisposes them to symptoms of anxiety, depression, and psychological distress.[5],[6] One would expect medical students to be better off than their peers in other walks of life when it comes to health, but it may not be true to certain extent as far as anxiety, depression and psychological distress are concerned.[7] No doubt medical science has made tremendous progress in terms of diagnosis and treatment of many human diseases but handling of mental disorders remain a challenge even today. The reasons being varied clinical presentations of mental illnesses, lack of specific diagnostic markers, poor compliance of treatment (which is generally long term), various myths and belief systems, and on top of all the social stigma.[8] Around 20% of the world's children and adolescents have derangement in mental homeostasis[9] and more than half of the medical undergraduates have been affected by depression, anxiety, and stress.[10] Medical schools around the world have stressful academic environment and that may have a negative impact on academic performance, physical health, and psychosocial well-being of some students'.[11] Previous studies conducted on this issue suggest that mental disorders are increasing at an alarming rate, and therefore, it is an important and growing public health issue.[12] Unfortunately, concrete steps have not been taken to create awareness among the public in general and students in particular for recognizing and combating mental illnesses. Medical students are quite prone to experience mental illnesses because they expect too much from themselves immediately after they enter the medical school. Expectations of family members, relatives, neighbors, and nonmedical friends to treat and counsel them during illnesses may put additional stress on them whether they accept it openly or not. Since medical students devote a lot of time in academic pursuits and they do not spare reasonable amount of time for hobbies, physical fitness, extracurricular activities, their stress is not released. The stress bubble which has built-up over the years may trigger depression, anxiety and each one in isolation or combination may affect quality of life (QOL)[13] leading to psychological morbidity. The World Health Organization (WHO) has defined QOL as “an individual's perception of their position in life, in context of the culture and value systems in which they live, and in relation to their goals, expectations, standards and concerns.”[14]

In our country, the selection process of medical students is contingent upon scores and rank based on written multiple choice questions-based entrance examination as opposed to the elaborate multi-aspect assessment conducted in the Western world where the students exercise explicit autonomy in deciding their careers.[15] Furthermore, the selection to prestigious residency program is again purely based on scores and rank in written multiple choice questions-based postgraduate entrance examination. This system of selection process of medical students in the country is bound to cause stress, depression, anxiety, and warrants changes.[16] The National Survey Report of 2005 found that around 10% of undergraduates were “seriously considering attempting suicide.”[17] Another National survey conducted by directors of college counselling centers in 2005 reported 92% increase in psychological problems among students.[18] In December 2011, the WHO predicted that depression will be the leading cause of disease burden globally by 2030.[19]

A meta-analysis carried out by Puthran et al. suggest that depression affects approximately 33.33% of medical students worldwide,[20] it varied from 8.7% to 71.3% among medical students studying in India. Sarkar et al. in their research conducted at the All India Institute of Medical Sciences, New Delhi, India, have found that about a third of the medical students are affected by prominent anxiety symptoms.[16] Studies conducted in Newcastle (Australia), Rochester ((Minnesota, USA), and Cambridge (UK) revealed that the prevalence of anxiety and depressive disorders among medical students is high globally as well.[21],[22],[23] Rotenstein et al. concluded that the overall prevalence of depressive symptoms among medical students is higher than the general population.[24]

It has been reported that frequent examinations (be it periodic tests in different subjects, terminal examinations, ward leaving viva-voce, etc.) are some of the common and continuous stressors to medical students[25] leading to anxiety.[26] Fear of poor performance at examinations, overwhelming load of new and massive information to learn, lack of time to revise the subjects, etc., have been identified as the causes of stress.[27] Nonetheless factors such as medium of previous education, living conditions, home and hostel may also affect the mental homeostasis of medical students.

Studies conducted by Hall et al. and Adlaf et al. suggested that female students report greater levels of stress[28],[29] than men and also show higher rates of symptoms of depression, anxiety, and stress.[30] These findings can also be contextualized with literature concerning the general population, which too suggests that women are more likely to suffer from depression and anxiety as compared to men.[31]

We designed this study to evaluate the levels of stress, depression, anxiety, and QOL among medical students studying at J. N. Medical College, Aligarh, Muslim University, Aligarh and also among those preparing to write NEET UG (medical) entrance tests in future. It is well known that coping mechanisms are a necessity when dealing with stress, anxiety, and depression, we have also looked at the different coping mechanisms adopted by the students to ward off stress, anxiety, and depression. To the best of our knowledge, no such study has been conducted in the Aligarh city of North India.


  Materials and Methods Top


Study setting, design and period

We adopted a cross-sectional study design with a quantitative research approach. The study was conducted over a period of two months at a selected tertiary care medical college, coaching institutes, and senior secondary schools of Aligarh city, Uttar Pradesh, India.

Study population

Students of the AMU senior secondary schools; those preparing for medical entrance examinations and have joined various coaching institutes at Aligarh city; MBBS students of I, II, final professionals (Part 1 and 2), interns and the MBBS passouts preparing for PG entrance examination: All belonging to Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, UP, India. The study population has fulfilled the inclusion criteria of willingness to participate in the study and had filled informed consent form. However, students suffering from any chronic disease which required prescription medicines or those who did not complete and return the survey form were excluded from the study. The study protocol has been approved by the Institutional Ethics Committee. Two hundred and fifty-seven students were approached in the month of March and were given a week's time. Only two hundred and twenty students have completed and returned the questionnaire. The study lasted for 3 months.

Description of the sample collection tool

Samples were collected using 42-item self-administered the Depression Anxiety Stress Scales (DASSs) questionnaire[32] designed to measure the magnitude of three negative emotional states: Depression, anxiety, and stress.[33] The DASS depression focuses on reports of low mood, motivation, and self-esteem, DASS-anxiety on physiological arousal, perceived panic, and fear, and DASS-stress on tension and irritability.

The QOL assessment was done by the WHOQOL-BREF QOL assessment scale developed by the WHO.[34] The participants were asked to answer the short version of the WHO QOL Instrument (WHOQOLBREF), which is a self-administered questionnaire that measures Domain 1: Physical health, Domain 2: Psychological well-being, Domain 3: Social relationships and Domain 4: Environmental conditions, over the last 2 weeks.

The DASS and WHOQOL-BREF questionnaires were distributed among the participants through Google forms, E-mail or hard copy, and the data were collected in accordance with the protocol established by Reisbig et al. which employs an anonymous survey research design.[35]

Data processing and analysis

For drawing meaningful inference, the collected data were analyzed by the IBM SPSS (Statistical Package for Social Science), v20.0 software, Armonk, New York, USA. In the present study, factor analysis was used to group questionnaires through exploratory analysis and discover various subscales of stressing in different groups. Pearson's Chi-square was also applied to find out the association between groups based on gender. In addition, for testing equality of variance and means considering a single factor between any two groups, t-test was applied. The P value was determined to conclude significant and insignificant differences between groups. The data were also analyzed using one-way analysis of variance (ANOVA) followed by Tukey's honestly multiple comparison tests. Association between psychological traits and QOL was established by Pearson's correlation test.


  Results Top


Of the total 220 respondents, 124 (56.36%) were females. The mean scores of depression, stress, and anxiety of all respondents based on the severity of psychological traits are depicted in [Table 1]. On the basis of scores obtained from the DAAS-42 self-administered questionnaire, 83 respondents (37.7%) had extremely severe anxiety and 45 (20.0%) had extremely severe depression. However, only 24 (10.91%) were having extremely severe stress [Table 1]. Association between various psychological traits (such as depression, stress, and anxiety) and gender was clearly evident from the Chi-square alpha and the P values [Table 2]. The data revealed that the female respondents had relatively higher levels of depression, stress, and anxiety as compared to males under similar situations.
Table 1: Distribution of study participants based on severity of the psychological traits

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Table 2: Distribution of severity of psychological traits among students in relation to gender

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One-way ANOVA showed significantly higher levels of depression, stress, and anxiety in 11th and 12th pursuing and 12th passed students preparing for national eligibility cum entrance tests (NEET-UG), final professional part 2 respondents and intern as compared to most of the other respondents [Table 3]. However, the respondents who were preparing for their NEET PG examination showed significantly low levels of depression, stress and anxiety; this could be possibly due to the very low number of participants in this group. Confidence interval for depression, stress, and anxiety was higher in 12th passed students preparing for NEET UG as compared to all other respondents [Table 2].
Table 3: One-way analysis of variance for association of Depression Anxiety Stress Scale score with different educational level of respondents

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Mean ± standard deviation of depression, stress and anxiety scores in relation to educational levels are presented in [Figure 1]. It is evident from the figure that students in first and second professional had relatively lower levels of depression, stress and anxiety scores as compared to other groups.
Figure 1: Relationship of educational level with depression (a), stress (b), and anxiety (c) scores

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The mean scores of all domains of QOL are shown in [Table 4]. First professional students had a significantly high mean score in all the four domains, namely physical, psychological, social, and environmental. There was a significant difference in the mean scores of physical, psychological QOL domains among 11th, 12th pursuing, 12th passed students preparing for NEET UG, first professional and final professional part 2 and interns [Table 4]. QOL scores are correlated with depression, stress, and anxiety using Pearson's Correlation [Table 5].
Table 4: Quality of life scores of respondents

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Table 5: Correlation of quality of life score with psychological traits

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Physical domain of QOL score showed strong negative correlation [Figure 2] with depression (r = −0.619; R2 = 0.383), stress (r = −0.563; R2 = 0.316), and anxiety (r = −0.524; R2 = 0.274) while psychological domain showed strong negative correlation only with depression. However, moderate negative correlation was observed between psychological domain with stress and anxiety. Social relationship domain also showed moderate negative correlation with depression, stress, and anxiety. However, only a small correlation was noted between depression, stress, and anxiety with environmental domain.
Figure 2: Correlation of domain 1 (physical health) with depression (a), stress (b), and anxiety (c)

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As far as coping mechanisms are concerned, most respondents used multiple strategies to cope up with their negative feelings, as depicted in [Figure 3]. Significant percentages (68%) of respondents consulted a psychiatrist or a psychologist to cope up with their stress, depression, and anxiety. Other methods such as taking some time alone (65%), meeting up with friends (63%), taking support from people who made them feel safe and cared for (56%), trying to keep up with social activities (56%), listening to music (50%), watching a funny movie or TV show (48%) were also used by a number of respondents. Doing something spontaneous (12%), exercise/yoga (11%), doing a few small tasks (7%) and listing what they liked about themselves (5%) were not very popular coping mechanisms among the respondents.
Figure 3: Relationship between the number of respondents and the coping mechanism opted by them

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  Discussion Top


It is widely held that some degree of stress is helpful to individuals in meeting new challenges, but persistently high and unrelieved stresses may lead to psychological, physical, and behavioral ill health. Depression, anxiety, and stress among medical students are often under recognized and under treated. Medical students also seldom seek professional help, mostly because of the shame and taboo that surrounds mental health.

In this study, we have found that depression, stress, and anxiety were strongly associated with gender. Our results are in close agreement with the findings of Kumar et al.,[36] who have reported higher scores of depression, stress, and anxiety among female medical students as opposed to their male counterparts. Interestingly, a similar pattern was also observed among students who were preparing for medical entrance examination. Furthermore, Roy et al. have reported higher depression scores among girls;[37] an observation similar to ours. However, our results of anxiety scores do not correlate well with the earlier report as we did not find association between gender and anxiety.[38]

The prevalence of depression, anxiety, and stress among 11th and 12th students and 12th passed students preparing for NEET UG, MBBS final professional (part 2) and interns, was significantly higher. While analyzing the relationship between students preparing for NEET PG and depression, stress, and anxiety, we found that the level of depression, stress, and anxiety was significantly low. However, with a limited number of sample size of the respondents preparing for NEET PG examinations, this outcome is not very meaningful. Our finding of higher psychological traits, especially in 11th and 12th pursuing and 12th passed students preparing for NEET UG, MBBS final professional (part 2) and interns, are not in agreement with earlier reports, which observed higher psychological traits in MBBS first professional students.[26],[39],[40] The observed higher psychological traits, especially in 11th and 12th students and 12th passed students preparing for NEET UG, MBBS final professional (part 2) and interns, may be attributed to greater fear of not achieving the goals.

Medical entrance tests as well as medical curricula are highly stressful and challenging. Many of those who pursue it or wish to pursue it suffer from psychological stresses which may lead to burnout and poor academic performances. QOL of these students is also affected. The World Health Organization (WHO) has defined health as a “state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” There is a growing recognition of the importance of maintaining or improving QOL. With this goal in mind, QOL was evaluated among premedical and medical students. Since depression, stress, and anxiety are associated with significant reduction in work capacity and therefore they affect the QOL.[41]

In this study, respondents who had higher depression, stress, and anxiety scores also had relatively lower scores of QOL in physical and psychological domains, which also concurs with many other studies.[41],[42]

Different individuals use different strategies to cope up with negative state and associated life problems.[43] Approximately, 68% of respondents relied on medications to cope up with stress, depression, and anxiety. However, other methods such as taking some time alone, meeting up with friends, taking support from people who made them feel safe and cared for, trying to keep up with social activities, listening to music, watching a funny movie or TV show were also popular among respondents.

The strength of the study is the comparison of stress levels among medicine pursuing students and aspirants. Our sample has equal representation of males and females which is another strength of the study. Online assessment without face to face interview is a major limitation of the study. Another limitation could be the lack of information regarding place of stay, food, financial aspects that could have contributed toward stress/psychological well-being. Being unable to keep track of class tests (if any) during the assessment period is a limitation.


  Conclusion Top


The present study has found that depression, stress, and anxiety are inter-related among premedical and medical students. This may have a detrimental effect on the overall health and performance of the students. It is the need of the hour to make school, medical teachers, and students aware of the negative consequences of high levels of stress, anxiety, and depression. However, there is still a long way to go. A lot of further research is required to determine the fault in the current education system so that remedial steps on medical health may be taken up.

Acknowledgment

Ms. Manal Khursheed is thankful to the Indian Council of Medical Research, New Delhi for the STS project awarded to her vide ID No. 2019-01074 and this paper is the outcome of that project. Authors are also thankful to (Drs.) Mohd. Nayyer Raman, AMU, Aligarh, India and Sana Shahab, PNU, Riyadh, Saudi Arabia, for their assistance in carrying out statistical analysis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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