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Review Article

A Systematic Review of Depression, Anxiety, and Stress among

Medical Students in India
Siddharth Sarkar, Rishi Gupta, Vikas Menon1
Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, 1Department of Psychiatry, Jawaharlal
Institute of Postgraduate Medical Education and Research, Puducherry, India

Abstract
Background and Objectives: The vicissitudes and stresses of medical education in India have been suggested to be different from that of
the Western world. Several studies have attempted to assess the psychological morbidity among medical students in India. This systematic
review attempted to collate the findings relating to the prevalence of depression, anxiety, and stress among medical students in India.
Materials and Methods: Studies were identified using PubMed, Embase, MedInd, and Google Scholar databases. Those studies conducted
in India which reported the prevalence of depression, anxiety, and stress among the medical students were included. Pooled prevalence rate
was calculated for depression, anxiety, and stress. Results: The prevalence rate of depression varied from 8.7% to 71.3%, while the pooled
prevalence rate of depression from 16 studies (n = 3882) was 39.2% (95% confidence interval: 29.0%–49.5%). Similarly, the pooled prevalence
rate of anxiety from four studies (n = 686) was 34.5% (95% confidence interval: 10.1%–58.9%), and the pooled prevalence rate of stress from
28 studies (n = 5354) was 51.3% (95% confidence intervals: 42.8%–59.8%). Female students had higher rates of depression and stress as
compared to males. Conclusions: Depression, anxiety, and stress affect a considerable proportion of undergraduate medical students in India.
Systemic efforts are needed to address their concerns and make mental health care easily accessible to them.

Keywords: Anxiety, depression, India, medical students, review, stress

Introduction medical education system has some unique features which

Graduate medical studies are considered one of the most
stressful professional courses.[1,2] High expectations from
self and family members, coupled with the training for
assuming responsibility for the well‑being of the patient,
make a medical student prone to experience stress which may
become excessive.[3] In addition, medical students need to
devote time for their academic pursuits and are often not able
to spare reasonable time for hobbies and relaxing pursuits.[4]
The accumulating stress is likely to have several deleterious
effects on medical students including academic jeopardy and
poor quality of life.[5] Thus, high rates of depression, anxiety,
and stress can result in poor quality of life and high rates of
psychological morbidity.
Psychological symptoms of anxiety, depression, and stress
among medical students have been reported from across the
globe.[6‑11] Systematic reviews have been conducted upon
studies reporting anxiety and depression among medical
students from different parts of the world. [12‑14] Indian
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make it different from other regions. First, the selection
process of medical students is contingent upon scores and
rank on an entirely written multiple choice questions‑based
entrance examination, whereas in the Western countries,
a personal statement, interviews, and extracurricular
records are also given due weightage for the assessment of
candidates, besides other things such as voluntary service
and research.[15] Second, family influences play an important
role in the decision of the student to pursue a career in
medicine.[16] This is different from the “Western” world
where the students exercise explicit autonomy in deciding
their careers. Third, the selection into lucrative residencies
Address for correspondence: Dr. Siddharth Sarkar,
Department of Psychiatry, National Drug Dependence Treatment Centre,
All India Institute of Medical Sciences, Ansari Nagar,
New Delhi ‑ 110 029, India.
E‑mail: sidsarkar22@gmail.com
This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non-commercially, as long as appropriate credit
is given and the new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com

DOI: How to cite this article: Sarkar S, Gupta R, Menon V. A systematic review
10.4103/jmhhb.jmhhb_20_17 of depression, anxiety, and stress among medical students in India. J Mental
Health Hum Behav 2017;22:88-96.

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Sarkar, et al.: Depression, anxiety, and stress in medical students
is based on the academic performance in single entrance
examination after the medical graduate course. This leads to
continued pressure of securing a good position and emphasis
only on academic performance to get a residency of choice.
Given the differences in considerations of medical education,
it becomes imperative to consolidate the evidence pertaining
to depression, anxiety, and stress in the Indian context.
Till date, there is no systematic review assessing these
psychological issues focusing upon Indian medical students.
Hence, this systematic review aimed to assess depression,
anxiety, and stress among medical students from India.
Materials and Methods
Objectives
The primary objective was to assess the prevalence of anxiety,
depression, and stress among medical students in Indian
medical colleges. The secondary objective was to assess the
relationship of anxiety, depression, and stress among medical
students with gender.
Search strategies
The present review used electronic searches with PubMed,
Embase, and MedInd databases supplemented with Google
Scholar search. All studies published from January 1970
to October 2015 were reviewed. The search expression
used for PubMed was  ([Medical students] OR  [Medical
undergraduates] OR [MBBS students]) AND (depress* OR
anxiety OR stress*) AND  [India OR Indian]. Other
synonymous expressions were also utilized to conduct the
literature search in Google Scholar. Further studies were
identified from the bibliographies of the studies screened
during the literature review. Searches were carried out in the
months of November and December 2015 by SS and RG.
Title/abstract screening was done by SS and RG, and articles
were selected with mutual consensus. The present study
primarily relied on electronic searches and hand searches
were not carried out as a part of this review.
Study inclusion
Studies were included if they had reported the prevalence
rate of anxiety, depression, or stress and were published in
peer‑reviewed English‑language journals. Studies which had
reported the proportion of students who had aforementioned
psychological morbidity were included, but those studies
which had only reported the mean and/or standard deviation
of anxiety, depression, or stress scores were not included.
Studies conducted in heterogeneous group of students
from different courses were included if they had reported
psychological morbidity in medical students separately.
Conference abstracts were not included in the present
systematic review. Those studies which reported other
psychological attributes such as sleep, quality of life, and
personality parameters without reporting the prevalence of
depression, anxiety, or stress were excluded. Older studies
which were only in print issue and not accessible online were
also not included.
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Data extraction
The studies which fulfilled the inclusion and exclusion
criteria were assessed in detail. Information that was extracted
from the records included author and year of the study,
the study location, sample size and sampling method, the
method/definition of depression, anxiety, or stress, and the
prevalence rate. In case the study reported several variables of
interest, then prevalence rate according to all the assessment
methods was recorded. Data extraction was done by RG and
SS. Clarifications and doubts if any were sorted out by mutual
discussion.
Quantitative analysis
The prevalence rate of depression according to each of the
studies was extracted from the published papers. Pooled
prevalence rate was computed for depression, anxiety, and
stress using the random effects model. Computation of
pooled prevalence rates and 95% confidence intervals was
done using Excel chart application.[17] Pooled analysis was
conducted for psychological attributes which had at least
three relevant studies. Random effects model was used given
the heterogeneity in the methods of assessment and the
prevalence rates reported. The I2 test of heterogeneity was
used to assess the heterogeneity of reported prevalence rates,
with higher values reflecting greater degree of heterogeneity.
Wherever available, the odds ratio of anxiety, depression, and
stress among males and females was computed. The pooled
odds ratio of depression and stress among male and female
medical students was computed along with the 95% confidence
intervals. Sensitivity analysis or meta‑regression analysis was
not conducted as a part of this review. We also did not attempt
a qualitative analysis of the studies.
Results
A total of 44 studies were included in the review [Figure 1].
Among them, 16 studies reported prevalence rates of
depression, 4 reported prevalence rates of anxiety, and 2 did
not distinguish between anxiety and depression.
Forty‑five studies were excluded. Nineteen studies were
excluded because they did not specifically give the prevalence
rate for anxiety/depression/stress.[18‑36] Thirteen were excluded
because they were conference abstracts.[37‑49] Seven dealt with
examination‑related stress.[50‑56]. Four were not relevant.[57‑60]
Two dealt primarily with sleep.[61,62]
A total of 16 studies were identified which reported depression
in medical students in India  [Table  1]. The most common
instrument used was Beck Depression Inventory, followed by
other rating scales including Primary Health Questionnaire‑9,
Depression Anxiety Stress Scale, Quick Inventory of
Depressive Symptomatology, Center for Epidemiological
studies‑Depression scale, Hamilton Depression Rating Scale,
and Kutcher Adolescent Depression Scale. The sample
sizes of the studies varied from 90 to 421. The prevalence
rate of depression varied from 8.7% to 71.3%. The pooled
prevalence rate of depression for the sample (n = 3882) was
89
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Figure 1: Identification and inclusion of the studies
Table 1: Studies evaluating depression and/or anxiety among medical students
Author, year
Depression
Baste and Gadkari, 2014[63]
David and Hashmi, 2013[64]
Devi et al., 2013[65]
Gupta and Basak, 2013[66]
Iqbal et al., 2015[67]
Kumar et al., 2012[68]
Manjunath and Kulkarni, 2013[69]
Modi and Kumar, 2013[70]
Prakash and Prabhu, 2014[71]
Sahu et al., 2013[72]
Sarkar et al., 2013[73]
Sidana et al., 2012[74]
Singh et al., 2010[75]
Vankar et al., 2014[76]
Venkatesh et al., 2014[77]
Verma et al., 2013[78]
Anxiety
Bassi et al., 2014[79]
Iqbal et al., 2015[67]
Modi and Kumar, 2013[70]
Pahwa et al., 2008[80]
Depression and anxiety
Amritha et al., 2013[81]
Srivastava et al., 2007[82]
CES‑D: Center for Epidemiological Studies‑Depression Scale
90
Sarkar, et al.: Depression, anxiety, and stress in medical students
39.2% (95% confidence interval: 29.0%–49.5%) using random
effects model. The I2 test of heterogeneity value was 5.3. The
forest plot of the studies included in the review reporting
findings on anxiety and depression is shown in Figure 2.
Four studies evaluated anxiety symptoms among students,
while two of them looked at anxiety and depression together.
The instruments utilized included Hamilton Anxiety Scale,
Depression Anxiety Stress Scale, Beck’s Anxiety Inventory,
Hospital Anxiety Depression Scale, and in‑house‑developed
instruments. The rates varied from 3.3% to 54.3% for anxiety,
while they ranged from 13.3% to 93.8% for symptoms
of anxiety and depression taken together. For anxiety, the
pooled prevalence rate of the sample  (n  =  686) was 34.5%
(95% confidence interval: 10.1% to 58.9%) using random
effects model, and the I2 value was 0.
Table  2 depicts the studies which had reported the rates of
psychological stress or distress. A variety of instruments had been
utilized to assess stress. While many of the studies used self‑rated
questionnaires, others have used structured questionnaires
such as the General Health Questionnaire, Depression Anxiety
Place of conduct Sample size, method Assessment method Prevalence
rate (%)
Mumbai, Maharashtra 90, random sampling Quick Inventory of Depressive 50.0
Symptomatology
Hyderabad, Telangana 128, convenience (1st year) Beck Depression Inventory 11.7
Puducherry 235, stratified random Beck Depression Inventory 71.0
West Medinipur, West 150, convenience Beck Depression Inventory 45.3
Bengal
Bhubaneshwar, 353, convenience Depression Anxiety Stress Scale 17.6
Odisha
Mangalore, Karnataka 400, stratified random sampling Beck Depression Inventory 71.3
Mysore, Karnataka 211, convenience CES‑D 45.5
Karamsad, Gujarat 92, convenience (final year) Self‑designed questionnaire 8.7
Tumkur, Karnataka 400, convenience Beck Depression Inventory 64.3
Nanded, Maharashtra 421, convenience Beck Depression Inventory 27.1
Kolkata, West Bengal 183, convenience Beck Depression Inventory 41.1
Delhi 237, stratified random Patient Health Questionnaire‑9 21.5
Bareilly, Uttar 336, convenience Beck Depression Inventory 49.1
Pradesh
Gujarat 331, convenience Patient Health Questionnaire‑9 64.0
Davangere, Karnataka 215, convenience Kutcher Adolescent Depression Scale 14.0
Bareilly, Uttar 100, convenience (1st years) Hamilton Depression Rating Scale‑17 31.0
Pradesh
Amritsar, Punjab 150, convenience Hamilton Anxiety Scale 49.3
Bhubaneshwar, 353, convenience Depression Anxiety Stress Scale 42 33.4
Odisha
Karamsad, Gujarat 92, convenience (final year) Self‑designed questionnaire 54.3
Pune, Maharashtra 91, convenience (first year) Beck’s Anxiety Inventory 3.3
Puducherry 400, stratified random sampling Hospital Anxiety Depression Scale 69.3
Pune, Maharashtra 105, convenience Anxiety/depression 13.3
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Sarkar, et al.: Depression, anxiety, and stress in medical students

Stress Scale, Professional Life Stress proforma, Presumptive
Life Stress Questionnaire, Stress Management Questionnaire,
Psychological General Well‑Being scale, Zung Scale for Stress,
Perceived Stress Scale, and others. The sample size varied from
36 to 493, and the prevalence varied from 5.0% to 96.8%. The
pooled prevalence rate of the sample (n = 5354) was 51.3%
(95% confidence interval: 42.8%–59.8%) based on random
effects model. The I2 test of heterogeneity value was 34.6. The
forest plot of the studies included in the review reporting findings
on stress is shown in Figure 3.
The gender differences in the rates of anxiety, depression, and
stress are depicted in Table 3. There was heterogeneity in the
gender predominance of symptoms of anxiety, depression, and
stress. On pooled analysis, males were less likely than females
to have depression (odds ratio of 0.85, 95% confidence interval:
0.73–0.96) and stress  (odds ratio: 0.90, 95% confidence
interval: 0.81–0.99).
Discussion
This systematic review suggests that depression affects roughly
two‑fifths of the medical undergraduate students, while stress
affects more than half of the students of medical courses,
though there was a marked variation in the reported rates of
depression and stress across the studies. Female students were
more likely to be affected by depression and stress as compared
to male students.
The reported rates of depression in the present review among
Indian studies varied from 8.7% to 71.3%. Even with Beck
Depression Inventory, the most commonly used instrument
used for assessment of depression in the Indian studies, the
rates of depression ranged from 11.7% to 71.3%. The cutoff
chosen for an individual to be classified as depressed would
also make a difference to the rates of depression, though
typically a cutoff of 10 and above is used for Beck Depression
Inventory. Studies from other parts of the world have also
found a wide range of prevalence of depression among medical
students,[14] though a substantial proportion of medical students
have been reported to be affected.[12,14] Though a fewer number
of studies addressed anxiety, it seems that about a third of the
medical students are affected by prominent anxiety symptoms.
The present review suggests that more than half of the students
suffered from considerable stress. Stress can be conceptualized

Figure 2: Forest plot of studies on anxiety or depression included in the Figure 3: Forest plot of studies on stress included in the review. Studies
review. Studies identified as author, year identified as author, year

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Table 2: Studies evaluating stress and mental distress among students

Author, year Place of conduct Sample size, method Assessment method Prevalence
rate (%)
Abraham et al., 2009[83] Manipal, Karnataka 115, convenience General Health Questionnaire 37.4
Baste and Gadkari, 2014[63] Mumbai, Maharashtra 90, random sampling Self‑administered questionnaire 54.4
Behere et al., 2011[84] Wardha, Maharashtra 100, random sampling Stress Measurement Scale 5.0
Brahmbhatt et al., 2013[85] Mangalore, Karnataka 200, convenience Perceived Stress Scale 42.5
Chatterjee et al., 2012[86] Kolkata, West Bengal 414, random sampling SRQ 14.5
Das et al., 2013[87] Kolkata, West Bengal 493, convenience PGWB scale 34.1
Deepali et al., 2015[88] Tumkur, Karnataka 100, convenience Perceived Stress Scale 62.0
Gupta et al., 2015[89] Kolkata, West Bengal 81, convenience MSSQ‑40 91.4
Iqbal et al., 2015[67] Bhubaneshwar, Odisha 353, convenience Depression Anxiety Stress Scale 13.3
42
Khaliq et al., 2010[90] Delhi 117, convenience Professional Life Stress proforma 59.8
Kittu and Patil, 2013[91] Puducherry 235, convenience Self‑administered instrument 71.1
Konjengbam et al., 2015[92] Imphal, Manipur 299, convenience General Health Questionnaire 28.4
Madhyastha et al., 2014[93] Manipal, Karnataka 94, convenience Professional Students Stress 56.4
Survey
Mahawar et al., 2011[94] Indore, Madhya Pradesh 60, convenience General Health Questionnaire 86.7
Manjunath and Kulkarni, 2013[69] Mysore, Karnataka 211, convenience General Health Questionnaire 25.1
Mannapur et al., 2010[95] Bagalkot, Karnataka 251, convenience Presumptive Stressful Life Events 47.0
Scale
Mehta et al., 2015[96] Amritsar, Punjab 339, stratified random sampling SRQ‑20 15.0
Modi and Kumar, 2013[70] Karamsad, Gujarat 92, convenience (final year) Self‑Designed Questionnaire 45.7
Nair, 2013[97] Raichur, Karnataka 245, convenience Kessler 10 Questionnaire 58.8
Nandi et al., 2012[98] Kolkata, West Bengal 215, convenience General Health Questionnaire 52.6
Reang and Bhattacharya, 2013[99] Agartala, Tripura 146, random sampling General Health Questionnaire 94.5
Saxena et al., 2014[100] Dehradun, Uttaranchal 100, convenience Self‑Rated Questionnaire 100.0
Sharma et al., 2011[101] Indore, Madhya Pradesh 68, convenience Zung Scale for Stress 67.6
Sivan and Rangasubhe, 2013[102] Kerala 96, convenience (first year) MSSQ Cohen’s Perceived 93.8
Stress Scale General Health 69.8
Questionnaire 65.6
Solanky et al., 2012[103] Surat, Gujarat 160, convenience Self‑Rated Questionnaire 96.8
Srinivasan et al., 2006[104] Bengaluru, Karnataka 36, convenience Self‑Rated Questionnaire 25.0
Supe, 1998[105] Mumbai, Maharashtra 238, random sampling Self‑Rated Questionnaire 74.8
Waghachavare et al., 2013[106] Sangli, Maharashtra 406, convenience Self‑Rated Questionnaire 25.1
PGWB: Psychological General Well‑Being, SRQ: Self‑Reporting Questionnaire, MSSQ: Medical Student’s Stressor Questionnaire

in various ways,[107] and diversity exists in the manner in which
stress has been operationalized. Some amount of stress is
adaptive and helps to trigger the hormonal response needed
to counter situations that are challenging emotionally and
physiologically.[108] However, the aim of this review was to
find pathological stress or distress, which may have adverse
outcomes in general. The individual studies included in the
review were heterogeneous in their definition of stress, and
the reported prevalence rates varied from 5.0% to even 100%.
Comparison of male and female students suggested that
female students were more likely to suffer from depression
and stress, as compared to male students. This is in line with
previous literature which suggests that female medical students
have higher rates of symptoms of depression, anxiety, and
stress.[14,109,110] The findings can also be contextualized with
literature among the general population, which suggest that
women are more likely to suffer from depression and anxiety
than men.[111] Men, on the other hand, are likely to suffer from
substance‑use disorders,[112] which, however, was not analyzed
in the present systematic review.
The high rates of depression, anxiety, and stress noted in this
review are worrisome. This reflects that the medical students
are likely to experience considerable degree of psychological
morbidity. Students are likely to be primed for the medical
course being a tough one at the time of preparation for the
entrance examination. Yet, many of them are not able to cope
effectively with the stress that the medical school training
entails. The genesis of anxiety, depression, and stress among
medical students may be multifactorial. The inability to
cope with the vast curriculum; repeated examinations; high
expectations of the parents, teachers, and patients, and time
constraints for pursuing their alternate interests may be
contributory.[85,102] Depression, anxiety, and stress among
medical students are often underrecognized and undertreated.
Stigma surrounding mental health issues often deters medical
students from seeking professional help.[113] Hence, medical

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Table 3: Gender differences in depression, anxiety, and stress

Author, year Attribute Assessment method Prevalence rate in males OR, male:female
assessed and females (%)
Bassi et al., 2014[79] Anxiety Hamilton Anxiety Scale 30.8, 63.5 0.25 (0.13-0.51)
Iqbal et al., 2015[67] Anxiety Depression Anxiety Stress Scale 42 25.5, 21.1 1.28 (0.77-2.11)
David and Hashmi, 2013[64] Depression Beck Depression Inventory 6.5, 11.0 0.57 (0.15-2.20)
Iqbal et al., 2015[67] Depression Depression Anxiety Stress Scale 42 24.8, 21.1 1.23 (0.75-2.04)
Kumar et al., 2012[68] Depression Beck Depression Inventory 70.5, 72.1 0.92 (0.60-1.43)
Manjunath and Kulkarni, 2013[69] Depression CES‑D 25.5, 24.8 1.04 (0.56-1.94)
Prakash and Prabhu, 2014[71] Depression Beck Depression Inventory 62.2, 60.6 1.07 (0.71-1.61)
Sahu et al., 2013[72] Depression Beck Depression Inventory 35.2, 38.9 0.85 (0.54-1.36)
Sidana et al., 2012[74] Depression Primary Health Questionnaire‑9 19.8, 23.4 0.81 (0.44-1.50)
Singh et al., 2010[75] Depression Beck Depression Inventory 42.4, 60.4 0.48 (0.31-0.76)
Verma et al., 2013[78] Depression Hamilton Depression Rating Scale 27.8, 34.8 0.72 (0.31-1.69)
Chatterjee et al., 2012[86] Stress SRQ 12.0, 20.7 0.52 (0.30-0.93)
Iqbal et al., 2015[67] Stress Depression Anxiety Stress Scale 42 34.4, 28.8 1.30 (0.82-2.05)
Mehta et al., 2015[96] Stress SRQ‑20 13.0, 16.3 0.76 (0.41-1.43)
Nandi et al., 2012[98] Stress General Health Questionnaire 50.0, 60.0 0.67 (0.36-1.24)
Sharma et al., 2011[101] Stress Zung Scale for Stress 66.7, 69.0 0.90 (0.32-2.52)
Sivan and Rangasubhe, 2013[102] Stress Medical student’s Stressor Questionnaire 94.1, 93.5 1.17 (020-6.74)
Sivan and Rangasubhe, 2013[102] Stress Cohen’s Perceived Stress Scale 64.7, 72.6 0.59 (0.25-1.42)
Sivan and Rangasubhe, 2013[102] Stress General Health Questionnaire 55.9, 71.0 0.46 (0.19-1.07)
Supe, 1998[105] Stress Self‑Rated Questionnaire 74.2, 72.7 1.08 (0.61-1.92)
CES‑D: Center for Epidemiological Studies‑Depression Scale, SRQ: Self‑Reporting Questionnaire, OR: Odds ratio

students do not seek formalized care for psychological distress,
despite such a facility being available at close quarters. In
addition, it is possible that medical students may feel that
developing resilience is a part of becoming a doctor and hence
distress would need to be endured as a part of the training.
The issue that arises is what can be done for the medical
students who experience psychological distress. Several
approaches and strategies can be utilized that can extend timely
help to the students. First, students who join the undergraduate
medical course can be made aware about the early symptoms
of anxiety and distress, and can be told where to seek help in
the hospital premises. Often, the fresh medical students are
uninitiated about the process and access options of mental
and physical health care. Hence, giving due information may
empower them to seek help in an appropriate manner, rather
than seeking informal advice from seniors and peers. Second,
the mental health‑care services can be made more accessible
to students. This may involve approaches such as having a
dedicated psychological help clinic in the campus or having
alternate means of communication through a helpline or
E‑mail. Third, peer mentorship programs can help students
relate to seniors and share their concerns with them. Peer
mentorships may help to detect problems early and bring them
under the care umbrella sooner. Fourth, informal channels of
consultation by psychiatrists and clinical psychologists may
be considered, especially for cases where the student is not
clear whether the distress requires clinical attention or not.
A brief assessment would help to clarify whether the student
would need clinical attention and treatment in the form of
psychotherapy and/or medications. Fifth, health promotion and
resilience‑enhancing measures may be considered. Life skills’
counseling that emphasizes on effective methods of dealing
with stress might be helpful in making the students more
adept at dealing with stressors. The above‑discussed means
and methods are not mutually exclusive, and one or more of
the above can be implemented based on providers’ and users’
expressed priorities.
Much of the literature included in the review originated from
the states of Karnataka, West Bengal, and Gujarat. The largest
number of studies from Karnataka is in line with the highest
number of medical colleges in this state. It is heartening to
know the interest of the researchers in understanding the
extent of psychological distress among the medical students
in the region. However, mental health researchers and medical
education facilitators from other parts of India also need to
be cognizant of the issues relating to psychological distress,
anxiety, and depression among medical students. Comparative
and collaborative research involving different medical schools
and using standardized instruments may help to give a more
accurate picture of medical students’ psychological morbidity.
The findings of this review need to be considered in view of
some strengths and limitations. The strengths include being the
first review of this kind from India and using pooled analysis
to derive the extent of depression, anxiety, and stress among
the student population. The limitations include focus on limited
aspects of psychological morbidity (i.e., prevalence rate and
male:female ratio) and exclusion of other psychological
attributes such as examination stress, sleep problems, and
substance‑use disorders. The review did not attempt sensitivity
analysis neither did it attempt at discerning prevalence rates

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Sarkar, et al.: Depression, anxiety, and stress in medical students
according to the region of origin or semester of the study.
Risk of publication bias and risk of bias for individual studies
could also not be assessed. The study has generalizability to
the Indian context, and caution needs to be exercised while
extrapolating the findings to other South Asian countries and
other parts of the world.
The present review may be considered as a launching pad for
future research designs with better methodology from India
on the topic of psychological morbidity in medical students.
These have been summarized in Box 1. First, there is a need
to conduct multicentric studies with the same methodology
and using comparable representative samples to assess
whether the differences in rates of depression and stress are
artifactual or are indeed present. Second, longitudinal studies
of medical students assessing depression, anxiety, and stress
of various time points may help in clarifying the stability of
the symptoms of psychological distress and remark on whether
distress subsides when the students get respite from coursework
during vacations. Such studies would also clarify whether
psychological distress increases or decreases with time. Third,
reporting of studies would improve if the methodology is
described in detail and ethical approval is specified clearly.
Fourth, the assessment of psychological morbidity may be
coupled with the evaluation of needs of treatment, i.e., what
forms of treatment would the students prefer and what barriers
they perceive in seeking treatment. Fifth, the assessment of
psychological morbidity may be paired with other external
validators such as quality of life and academic performance.
This would give a greater impetus toward addressing the
concerns of the students. Sixth, data from intervention trials in
this population need to be consolidated. Not only efficacy and
adverse effects, but also acceptability and issues in delivery are
needed to be highlighted (e.g., for psychotherapy).
Conclusions
The review suggests that a substantial proportion of medical
students suffer from depression, anxiety, and psychological
distress. Efforts are required to cater to medical students who
are distressed, in a nonintrusive manner. Awareness about
manifestations of distress among medical students needs to
be increased among not only students themselves, but also
other stakeholders such as medical educationists and parents.
Further research is required on this issue, and multicentric
longitudinal studies would help to provide better answers
about psychological distress among medical students in India.
Box 1: Future research needs
Multicentric studies with similar methodology across centers
Longitudinal studies
Detailed description of methodology and ethical approval
Addressing barriers to treatment
Assessing the mental health‑care needs of the students
Using other complementary outcome measures like quality of life
Intervention trials
94 Journal of Mental Health and Human Behaviour  ¦  Volume 22  ¦  Issue 2  ¦  July-December 2017
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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