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Original Article

Assessment of Depression, Anxiety, and Stress among Medical Students


Enrolled in a Medical College of New Delhi, India

Abstract Neha Taneja,


Objective: The objective of this study was to determine the prevalence of depression, anxiety, and Sandeep Sachdeva,
stress among medical students. Materials and Methods: Students underwent face‑to‑face interview Nidhi Dwivedi
using predesigned, pretested, anonymous interview schedule using standardized survey instrument
Department of Community
and Depression Anxiety Stress Scale 21 item. Information was also collected on sociodemographic,
Medicine, North DMC Medical
academic profile, and personal characteristics of students. All the students enrolled in the College and Hindu Rao
medical college from first to final year were invited to participate, and the study was conducted Hospital, New Delhi, India
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

Introduction from stress, interpersonal problems, and


suicidal ideation to psychiatric disorders.[1‑4]
Medical education is a full‑time
Globally, it has been demonstrated that
commitment and responsibility of students
25%–90% of medical students are stressed,
that entails academic tasks, activities, social
which is an important determinant of
conduct, support, and care provided to Address for correspondence:
depression and anxiety.[5,6] A systematic
patients. Mental health of a medical student Dr. Sandeep Sachdeva,
review of 183 studies from 43 countries Department of Community
remains affected throughout training due to
revealed crude prevalence of depression Medicine, North Delhi
long study and working hours, extensive
among medical students to be around 27.2% Municipal Corporation Medical
course content, examinations, peer College and Hindu Rao
(95% confidence interval: 24.7%–29.9%)
competition, un‑inspiring environments, Hospital, New Delhi ‑ 110 007,
with 11.1% prevalence of suicidal India.
sleep deprivation, and loneliness including
ideation.[7] On the contrary, a recent large E‑mail: sachdevadr@yahoo.in
other factors interfering in everyday
sample survey in southern part of India
personal, social, and family life. Medical
reported an overall prevalence of depression
education is generally perceived as
of 15.9% among general population.[8] Access this article online
being stressful and considerable degree
Website: www.indjsp.org
of psychological morbidity has been Students with dysfunctional emotional state
reported among medical students ranging need serious attention and management DOI: 10.4103/ijsp.ijsp_114_17
otherwise inability to cope successfully Quick Response Code:

Thisisanopenaccessjournal,andarticlesaredistributedundertheterms
of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 How to cite this article: Taneja N, Sachdeva S,
License, which allows others to remix, tweak, and build upon the work Dwivedi N. Assessment of depression, anxiety, and
non‑commercially, as long as appropriate credit is given and the new stress among medical students enrolled in a medical
creations are licensed under the identical terms. college of New Delhi, India. Indian J Soc Psychiatry
For reprints contact: reprints@medknow.com 2018;34:157-62.

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Taneja, et al.: Depression, anxiety, stress among medical students

may lead to adverse consequences at both personal and to some degree or some of the time = 1; applied to me to a
professional levels.[9] The demand for curbing mental health considerable degree or a good part of time = 2; and applied to
conditions, especially depression, is gaining momentum me very much or most of the time = 3. Scores for depression,
across the world since the last couple of decades.[10] It is no anxiety and stress are calculated by summing the scores for the
surprise that mental health of medical students in India as relevant items and analyzed as per guidelines. The tool is easy
an area of research domain has attracted the second highest to apply in both clinical and nonclinical settings and suitable
attention of the faculty in medical colleges of country after for use in different age groups including medical students.
medical education, learning process, and evaluation.[11] The data were analyzed using statistical
With this background, a study was undertaken to assess software, SPSS (ver. 20.0) (IBM Inc, Armonk, New York,
the prevalence of depression, anxiety, and stress among USA). Descriptive statistics and bivariate and regression
medical students enrolled in a government medical college analysis were carried out to find association and correlation
of New Delhi, India. and considered significant at P < 0.05. The internal
consistency, i.e., Cronbach’s alpha value was 0.87 that was
Materials and Methods
suggestive of high reliability.
The study population included all the medical students
enrolled in a government medical college from first to Results
final year. Students underwent face‑to‑face interview A total of 187 students participated in the study giving a
using predesigned, pretested, anonymous interview response rate of 94%. The profile of the study sample was
schedule after obtaining institutional ethical clearance and predominantly male (66%); hosteller (65.8%) with 63.3%
informed consent of the students. They were informed of students having one sibling. Nearly 24.1% and 34.6%
about the anonymous and voluntary nature of participation of students reported having ever smoked or consumed
in the study without any undue fear, stigma, or adverse alcohol, respectively. The overall mean age of students
documentation and were contacted during their free time. was 21.54 (standard deviation = 1.98) years. Table 1
The study was conducted during September 2017 to depicts sociodemographic profile of study participants.
ensure that the students were not having any university It was also found that 31.6% had a family history
examinations or college festival/event. of chronic noncommunicable disease; 11.2% further
A previously validated and standardized survey instrument, mentioned that there was a family history of chronic
Depression Anxiety Stress Scale (DASS 21), was used mental illness while 25.7% of students had suffered
to collect information on depression, anxiety, and with some medical conditions such as typhoid, malaria,
stress.[12,13] Additional information was also collected pneumonia, and hospitalization due to injury in the past
on sociodemographic, academic profile, and personal (not shown in table).
characteristics of students. Subjective (self) assessment of It was found that 60 (32.0%), 75 (40.1%), and 82 (43.8%)
ability to cope with syllabus and academic performance medical students were affected by symptoms suggestive
on a scale of 1–10 points, satisfaction with body image, of depression, anxiety, and stress, respectively. Details
admission in current medical college, and global satisfaction are shown in Figure 1. Some students were affected
with life was also assessed. Self‑assessment scale from 1 to by >1 emotional state. It was observed on bivariate
10 points was classified into low (1–4), medium (5–7), and analysis that higher proportion of students with anxiety
high (8–10) score. had a history of some medical condition and this was
DASS (21 item) is a short scale that allows simultaneous found to be statistically significant  (P < 0.05). Similarly,
assessment of the three emotional states of depression, family history of chronic noncommunicable disorder was
anxiety, and stress and each domain contains 7 items, significantly  (P < 0.05) associated with stress and family
divided into subscales with similar content. The depression history of mental illness with depression only. History of
scale assesses dysphoria, hopelessness, devaluation of life, smoking, alcohol intake, and enlisted other social factors
self‑deprecation, lack of interest/involvement, anhedonia, had no statistical association with any of the emotional
and inertia. The anxiety scale assesses autonomic arousal, state (not shown in table).
skeletal muscle effects, situational anxiety, and subjective Table 2 shows association of academic variables of students
experience of anxious affect. The stress scale is sensitive to with depression, anxiety, and stress, and it was found
levels of chronic nonspecific arousal. It assesses difficulty that enrollment batch and ability to cope with syllabus
relaxing, nervous arousal, and being easily upset/agitated, were statistically associated with depression, anxiety,
irritable/over‑reactive, and impatient. and stress (P < 0.05). Higher proportion of all the three
emotional distress states was found in the 1st‑year students
Respondents were asked to document on a 4‑point
in comparison to senior students (P < 0.05).
severity/frequency scales to rate the extent to which they
have experienced each state over the past week. The scale Table 3 depicts additional personal details of medical
is as follows: did not apply to me at all = 0; applied to me students affected by emotional state. It was noted that

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Taneja, et al.: Depression, anxiety, stress among medical students

Table 1: Sociodemographic profile of study We further studied the correlation between depression,
participants (n=187) anxiety, and stress and it was found that they were highly
Variable n (%) correlated with each other. The correlation coefficient value
Gender between depression and anxiety was 0.71, depression and
Male 124 (66.3) stress was 0.73, and anxiety and stress was 0.78.
Female 63 (33.7)
Religion
Discussion
Hindu 153 (81.8) This descriptive study using DASS‑21 scale was suggestive
Others 34 (18.2) of high prevalence of depression (32.1%), anxiety (40.1%),
Native place and stress (43.8%) among medical students enrolled
Delhi 109 (58.3) in a government medical college of metropolitan city,
Outside Delhi 78 (41.7) New Delhi, India. The predictors such as low ability
Residence to cope with syllabus and newly entrant students were
Hostel 123 (65.8) significantly  (P < 0.05) associated with the emotional
Day scholar 64 (34.2) distress. This study also reported protective factors such
Number of siblings as strong relationship with family members, negative
One 119 (63.3) history of medical condition, satisfaction with body image,
At least two 68 (36.4) and global satisfaction with life. Our study was held in
Students who have ever smoked the mid‑semester, to ensure that the students were not
Yes 45 (24.1) under the influence of any college event or examination.
Students who have ever consumed alcohol
However, a recent large sample survey in southern part
Yes 65 (34.6)
of India reported an overall prevalence of depression of
15.9% among general population.[8]
50
43.9%
In a similar study from Brazil using DASS scale, 34.6%,
45
40.1% 37.2%, and 47.1% of medical students suffered from
40
depression, anxiety, and stress, respectively.[14]  A study
Proportion (%)

35 32.1%
30 from Turkey found that 27.1% of students were depressed,
25 47.1% from anxiety, and 27% students were stressed. In a
20 study from Nepal, depression was reported to be 29.9%,
15 anxiety 41.1%, and stress 27% among medical students.[15]
10 A study based in the United States found 24% of medical
5
students to be depressed while another study from the
0
Depression Anxiety Stress US reported 12% of medical students to be diagnosed
with probable major depression using DSM III criteria.[16]
Figure 1: Percentage of medical students affected by the emotional states
In a study from Egypt, 43.9% of students were suffering
from anxiety.[17] Similar alarming statistics have been
7.5% reported parental conflict; 15.0% were “always” corroborated by our study also.
fearful about future life; 21.9% had poor relationship with
family members; 22.5% were unsatisfied with their body Studies conducted in various regions of India reflect diverse
image; and 18.7% were globally dissatisfied. It was found situation depending on the use of study instruments. In
that satisfaction with body image and global satisfaction a study from Bhubaneshwar (Odisha), the prevalence of
with life was statistically (P < 0.05) associated with depression, anxiety, and stress among medical students was
depression and anxiety while relationship with family 51.3%, 66.9%, and 53%, respectively, using DASS scale.[18]
members was statistically (P < 0.05) associated with Another study reported that 39.44% of students suffered
depression only. Higher proportion of student with from depression, 66.05% from anxiety, and 51.37% from
depression had fair (poor) relationship with their stress.[19] A Jodhpur (Rajasthan)‑based study found that
respective families. 57.98% of students depressed and 47.41% suffered from
anxiety.[20] Another Delhi‑based study found the overall
Subjective (self) assessment of ability to cope with medical
prevalence of provisionally diagnosed depressive and major
syllabus was inversely but statistically associated (P < 0.01)
depressive disorders among medical students to be 21.5%
with depression and anxiety, i.e., as the ability to cope
and 7.6%, respectively.[21] On the contrary, some studies
with syllabus increases, the probability of occurrence of
conducted two decades ago have found little or no evidence
depression and anxiety decreases. As shown in Table 4, one
of stress among medical students.[22,23]
unit improvement in ability to cope with syllabus results
in reduction of 1.29 units in depression and 0.71 units in On joining medical college, students embark their
anxiety. professional journey with high expectations and are loaded

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Taneja, et al.: Depression, anxiety, stress among medical students

Table 2: Academic profile of study participants affected by the psychological state


Variable Total (n=187), Depression (n=60), Anxiety (n=75), Stress (n=82),
n (%) n (%) n (%) n (%)
Enrollment batch (year of college admission)
Ist year 49 (26.3) 22 (36.7)* 28 (37.3)# 30 (36.6)ª
IInd year 47 (25.1) 16 (26.7)* 17 (22.7)# 19 (23.2)ª
IIIrd year 47 (25.1) 12 (20.0)* 16 (21.3)# 17 (20.7)ª
IVth year 44 (23.5) 10 (16.7)* 14 (18.7)# 16 (19.5)ª
No of attempts to join MBBS
First attempt 76 (40.6) 26 (43.3) 25 (33.3) 29 (35.4)
At least 2 attempts 111 (59.4) 34 (56.7) 50 (66.7) 53 (64.6)
Reason to join MBBS
Personal choice 164 (87.7) 55 (91.7) 66 (88.0) 72 (87.8)
Parents’ pressure 23 (12.3) 5 (8.3) 9 (12.0) 10 (12.2)
Awareness of vastness of medical course before joining
MBBS
Yes 137 (73.3) 41 (68.3) 53 (70.7) 60 (73.2)
No 50 (26.7) 19 (31.7) 22 (29.3) 22 (26.8)
Number of supplementary examinations
None 158 (84.5) 52 (86.7) 64 (85.3)# 73 (89.0)
At least one 29 (15.5) 8 (13.3) 11 (14.7)# 09 (11.0)
Satisfaction with regard to admission in this college
Satisfied 148 (79.1) 46 (76.7) 58 (77.3) 67 (81.7)
Unsatisfied 39 (20.9) 14 (23.3) 17 (22.7) 15 (18.3)
Satisfaction with regard to MBBS as a professional carrier
Satisfied 173 (92.5) 55 (91.7 ) 69 (92.0) 79 (96.3)
Unsatisfied 14 (7.5) 5 (8.3) 6 (8.0) 03 (3.7)
Subjective (self) assessment of ability to cope with
medical syllabus on a scale of 1-10 points
1-4 (low) 15 (8.0) 3 (5.0)* 7 (9.3)# 09 (11.0)ª
5-7 (medium) 123 (65.8) 46 (76.7)* 46 (61.3)# 52 (63.4)ª
8-10 (high) 49 (26.2) 11 (18.3)* 22 (29.3)# 21 (25.6)ª
Subjective (self) assessment of academic performance on
a scale of 1-10 points
1-4 (low) 35 (18.7) 14 (23.3) 18 (24.0) 17 (20.7)
5-7 (medium) 123 (65.8) 37 (61.7) 45 (60.0) 55 (67.1)
8-10 (high) 29 (15.5) 9 (15.0) 12 (16.0) 10 (12.2)
*,#,ª
P<0.05

with lots of new information to be crammed which at image which is higher than another study conducted at
times become difficult to process. The students leave the Rohtak, Haryana (13.5%), with a predominantly rural
protected, pampered, and very supportive environment flavor.[25]
of their family and come to stay in hostel under highly The content of MBBS subject in medical colleges of India
competitive environment. This could be contributing to the is based on global best practices, and course duration is
higher prevalence of depression, anxiety, and stress seen in of four‑and‑half years followed by 1‑year internship. The
1st‑year medical students in this study. Similar observation students are systematically and in structured way exposed
was reported by Aktekin regarding worsening in overall to different subject streams (preclinical, paraclinical, and
mental health with high level of depression and anxiety clinical) through processes prescribed under regulatory
among 1st‑ and 2nd‑ year medical students.[1] Quince et  al. body with student to keep record of daily activity/learning
performed a longitudinal study at a UK medical school and in a log book followed by formative and summative
found a prevalence of depression ranging from 5.7% to evaluation.[26] It is no surprise that India is one of the
10.6% among students in the basic years and 2.7% to 8.2% popular destinations of medical, transplant, reproductive,
in students from clinical stages of the course.[24] Further, and health tourism in the world, and a substantial proportion
there was no significant difference of emotional state of renowned doctors working in developed country have
between males and females in our study. In our urban‑based roots in this great nation.[27,28] It could be partly attributed
study, 22.5% of students were unsatisfied with their body to rigor of professional training and the quality of learning

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Taneja, et al.: Depression, anxiety, stress among medical students

Table 3: Personal profile of study participants affected from the 2nd year onward.[30] It can be though attributed
by emotional state to early start and purposeful planning but also indicating
Variable n (%) Depression, Anxiety, Stress, a case scenario of intense peer pressure, uncertain future
n (%) n (%) n (%) environment, rising stress, and anxiety.
History of parental Medical students under strain are either unaware of their
conflict
situation or reluctant to seek help. High‑risk students
Yes 14 (7.5) 3 (5.0) 5 (6.7) 6 (7.3)
found in our study were provided personal and confidential
Fear of future life
counseling under additional supervision of mental health
Always 28 (15.0) 12 (20.0) 12 (16.0)# 11 (13.4)
expert.
Sometimes 127 (67.9) 42 (70.0) 55 (73.3)# 56 (68.3)
Never 32 (17.1) 6 (10.0) 8 (10.7)# 15 (18.3) Conclusion
Relationship with
friends Emotional distress is common among medical students,
Strong 93 (49.7) 28 (46.7) 33 (44.0) 42 (51.2) and there is a need for attention, support, and personalized
Fair 94 (50.3) 32 (53.3) 42 (56.0) 40 (48.8) counseling services.
Relationship with
family
Financial support and sponsorship
Strong 146 (78.1) 42 (70.0)* 56 (74.7) 62 (75.6) Nil.
Fair 41 (21.9) 18 (29.3)* 19 (25.3) 20 (24.3)
Satisfaction with
Conflicts of interest
body image There are no conflicts of interest.
Satisfied 145 (77.5) 44 (73.3)* 59 (78.7)# 64 (78.0)
Not satisfied 42 (22.5) 16 (26.7)* 16 (21.3)# 18 (22.0) References
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162 Indian Journal of Social Psychiatry | Volume 34 | Issue 2 | April-June 2018