Journal of Health Sciences (J of H Ss) 2013; 3(5): 29-38

The journal has had 4 points in Ministry of Science and Higher Education of Poland parametric evaluation. Part B item 683.

ACADEMIC STRESS DUE TO DEPRESSION AMONG MEDICAL AND

PARA-MEDICAL STUDENTS IN AN INDIAN MEDICAL COLLEGE:
HEALTH INITIATIVES CROSS SECTIONAL STUDY
Balkishan Sharma, Rajshekhar Wavare

© The Author(s) 2013;

This article is published with open access at Licensee Open Journal Systems of Radom University in Radom,
Poland

Dr. Balkishan Sharma Ph. D.

Corresponding Author
Associate Professor of Biostatistics,
Department of Community Medicine,
Sri Aurobindo Medical College and P. G. Institute, Indore, (M. P.), India;
E-Mail: bksnew@rediffmail.com & bksnew@gmail.com
Phone:(0731) 423101 and, Fax:(0731) 4231010

Dr. Rajshekhar Wavare M. D. (Community Medicine)

Co-Author
Professor & Head of Department,
Department of Community Medicine,
Sri Aurobindo Medical College and P. G. Institute, Indore, (M. P.), India;
E-Mail: rajwavare@rediffmail.com
Phone:(0731) 4231010 and Fax:(0731) 4231010

Abstract:
Introduction and aim: Stress is usually a precursor to anxiety and anxiety is usually a precursor
to depression, can reduce the efficiency of healthy individuals. This study is aimed to observe the
levels of depression, leads to stresses and its effect on vital parameters during academic
curriculum.
Materials and Methods: A prospective cross-sectional study is designed which conducted at Sri
Aurobindo Medical College and P. G. Institute, Indore, (M. P.) India. 132 final year MBBS and
Physiotherapy students of academic year 2012-13 were selected as subjects. The height, weight,
pulse rate and blood pressure were taken before and during pre-university examination. Zung’s
scale was used for assessment of depression.
Results: There was highly significant difference in vital parameters [PR (t=7.86, P<0.001), SBP
(t=5.39, P<0.001) and DBP (t=3.92, P<0.001)] during examination. The depression level was
high as Extreme major depression was observed in 7.9% of boys and 11.8% of girls from MBBS
and 10.7% of girls from Physiotherapy. SDS Index of depression was more in girls as compared
to boys.
Conclusion: It was observed that academic examinations for Medical and Para-medical students
are stressful and produce changes in vital parameters which affected their academic performance.
Academics and examinations are the most powerful stressors in Medical and Para-medical
students.
ACADEMIC STRESS DUE TO DEPRESSION AMONG MEDICAL ……..
Key Words: Depression, Stress, Anxiety, Stressor, Pulse rate and Vital Parameters.
Abbreviation: PR-Pulse Rate, SBP- Systolic Blood Pressure, DBP-Diastolic Blood Pressure
and SDS-Standardized Depression Scale
Introduction: Depression is a disorder of
mood involves varying levels of sadness and
despair associated with stress. Depression has
received a lot of attention in the media and is
far more widely accepted today than it has
ever been in the past. The term “stress” was
firstly employed in the 1930’s by the
endocrinologist Hans Selye [1]. Stress is a
response to any event which is perceived to
alter or threaten our well–being and is a
cognitive (thought) process; is the body's
reaction to a change that requires a physical,
mental or emotional response. Indian
education system resembles colonial legacy:
educational structure, curriculum design and
pattern of examination [2]. But too much
stress can cause a lot of discomfort and can
get in the way of being able to focus and
achieve.
As a college student all have a lot of demands
on them, which it can be difficult to balance.
Stress is a term in Psychology and Biology,
which in the more recent decades, has become
a common place of popular parlance [3].
Studies suggest that high levels of stress and
psychological morbidity occur in health care
profession students [4]. Considerable research
has investigated stressors and psychological
morbidity in medical, dental and nursing
students [5-9]. However, few studies have
been undertaken in physiotherapy students.
This study explores different levels of
depression acquired stresses and
psychological morbidity in undergraduate
medical and physiotherapy students.
Depression is actually a particular pattern of
disturbing psychological and physiological
reactions that occur when an environment
event threatens important motives. Depression
leads to stress which is caused by an existing
stress-causing factor or "stressor." All are
Journal of Health Sciences (J of H Ss) 2013; 3(5)
aware of fearfulness of examinations and
especially about practical examination in a
professional college. Whether it is a test or an
annual promotion examination, it does cause
to loose some sleep which leads to anxiety and
depression. It is confirmed the general
impression that there is a considerable amount
of stress among medical students [10] and the
perceived stress was significantly higher
among female students [11].
High levels of perceived stress existed in the
first and second year undergraduate medical
students [12]. Negative affect, depressive
mood, and salivary cortisol were elevated
during exams [13]. Stress, depression, and
troubled relationships may have synergistic
inflammatory effects: loneliness, subclinical
depression, and major depression enhance
inflammatory responses to an acute stressful
event [14]. Too much stress pooled with other
psychological factors can be damaging and
can disrupt normal functioning of the students.
It may lead to further psychological
complications causing psychological
morbidity. Subjective experience of stressors
in students can lead to poor quality of life,
condensed self-esteem resulting in lower self-
confidence, compromised ability to cope with
daily life problems and may influence
student's academic performance [15-16].
Students that drop out of professional
institutions actually do not lack intellectual
ability, but emotional problems and poor
motivation lead to failure [17]. Stressors
experienced by third-year medical radiation
sciences students during their clinical
education have been reported [18].
Various physiological studies have shown that
depression leads to stress and which can affect
the physical health even the vital parameters.
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ACADEMIC STRESS DUE TO DEPRESSION AMONG MEDICAL ……..
These changes include increase in pulse rate
and blood pressure. The present study was
aimed to assess the stress due to depression
and its effect on vital parameters during
academic examination in final year medical
and paramedical students.
Materials and Methods: A prospective cross-
sectional study is design to assess the levels of
depression, leads to stresses and its effect on
vital parameters during academic curriculum.
The study was carried out at Sri Aurobindo
Medical College and P. G. Institute, Indore,
(M. P.) India. The final year MBBS and
Physiotherapy students of academic year
2012-13 appearing for university examination
were selected as subjects. There were 148
students out of which 132 participated in the
study. Ethical approval was obtained from
Institutional research and ethical committee.
Two months prior to the academic
examination height (cm), weight (kg), Pulse
rate and Blood Pressure were recorded and
again during academic examination the same
was repeated. The observed mean age of
student was 21.00±2.54 years. Sixteen
students were excluded from the study as they
were absent during examination. After
explaining the purpose of the study a
questionnaire was provided to one student at a
time just before the start of viva-voce and was
asked to answer (fill up) the questions in
prescribed format so as to assess their
depression level.
Zung’s scale was used to assess the depression
level [19]. The questionnaire consists of
twenty questions where Likert Scale Format is
used for assessment and scoring of depression
level. Ten questions based on positive answers
and ten negative are included. Each question
has answer score from 1 to 4. The option for
each question is (a) None or a little of the time
(b) Some of the time (c) Good part of the time
and (d) Most or all of the time. The raw score
is converted to 100 point scale (SDS Raw
Journal of Health Sciences (J of H Ss) 2013; 3(5)
Index). SDS Raw Index=(Raw Score/80 total
points)x100 and SDS Index=SDS Raw
Index*1.25.The score obtained was analyzed
by using scale of depression according to
Zung’s categorization as <50 is Normal, <60
is Mild Depression, <70 is Moderate or
Marked Major Depression and >70 is Severe
or Extreme Major Depression. Pre readings
(before examination) for Pulse Rate, Systolic
Blood Pressure and Diastolic Blood Pressure
were compared with post readings (at the time
of examination). Body Mass Index was
calculated for all the students [20].
Statistics: The Data were entered into the
computer database. The responses of
frequencies were calculated and analyzed by
using statistical software SPSS version 11.0.
Prevalence of an outcome variable along with
95% confidence interval was calculated.
Student’s t-test for paired samples was used to
compare the mean values of study variable in
relation to depression. The descriptive
statistics like mean and standard deviation of
different study variables was calculated. The
Zung’s self rating depression scale [19] was
analyzed by categorization of the three levels
(Mild, Moderate or Marked Major and Severe
or Extreme Major Depression) of depression
as presence of depression. The probability
value p<0.05 was considered as significant,
p<0.01 and p<0.001 were considered as highly
significant.
Results: The findings reported that in MBBS
the boys and girls are equally distributed
whereas in physiotherapy 93% were girls.
This may be because of more number of girls
opting for physiotherapy course.
Table no 1 revealed the weight and height of
students of MBBS and Physiotherapy course.
The table 2 showed that of the total selected
subjects most of the students (58.3%) had
normal weight, 19.7% were overweight (pre
obese increased category-I), 10.6% in
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ACADEMIC STRESS DUE TO DEPRESSION AMONG MEDICAL ……..
underweight category and 3.8% were in
obesity. Major proportion of boys (68.4%) and
girls (58.8%) from MBBS course and (51.8%)
of girls from physiotherapy course were
normal weight. 28.9% boys and 17.6% girls
from MBBS course and (30.4%) of girls from
physiotherapy course were in pre obese
increased category-I. 23.5% and 8.9% girls
from MBBS and physiotherapy course
physiotherapy course were found to be
underweight respectively. It was also observed
that 8.9% of girls from physiotherapy course
were obese. The mean Body mass index for
boys was 23.01 kg/m2 and girls 21.44 kg/m2
of MBBS course and 24.05 kg/m2 for boys
and 23.95 kg/m2 for girls of physiotherapy
course while 23.03 kg/m2 was observed in the
total population.
The scale of depression according to Zung’s
categorization is; <50 is Normal, <60 is Mild
Depression, <70 is Moderate or Marked Major
Depression and >70 is Severe or Extreme
Major Depression. It is observed in the table 3
that 18.4% of boys and 35.3% of girls from
MBBS course and 25% of girls from
Physiotherapy were normal. It is also seen that
more than half (60.5%) of boys and more than
one-fourth (26.5%) of girls from MBBS
course and exactly three-fourth (75.0%) of
boys and approximately one-third (30.4%) of
girls from Physiotherapy had mild depression
whereas 13.2% of boys and 26.5% of girls
from MBBS course and 25% of boys and
33.9% of girls from Physiotherapy had
marked major depression. 7.9% of boys and
11.8% of girls from MBBS course and 10.7%
of girls from Physiotherapy suffered from
extreme major depression (table3).
The Mean Depression score (SDS Index) for
boys was 56.50 and girls 56.29 from MBBS
course and 56.25 for boys and 58.96 for girls
from Physiotherapy course while 57.48 was
observed in the total population. It was also
observed from the table 4 that the Mean
Depression Score (SDS Index) was more for
Journal of Health Sciences (J of H Ss) 2013; 3(5)
girls as compared to boys during their
academic examination. There was no
difference between Mean Depression Score
(SDS Index) in the students of MBBS and
Physiotherapy course during their academic
examination (Table-3). It is confirmed from
table 4 that there is a highly significant
difference between before and at the time of
examination observations in vital parameters
such as Pulse rate (p<0.001; two tailed),
Systolic Blood Pressure (p<0.001; two tailed)
and Diastolic Blood Pressure (p<0.001; two
tailed) due to examination stress in all the
students from MBBS and Physiotherapy
course (Table-4). Mean pre-readings in all the
students from MBBS and Physiotherapy
course for Pulse rate, Systolic Blood Pressure
and Diastolic Blood Pressure were
77.52  7.75 per minute, 120.29  9.66 mm of
Hg and 81.07  8.71 mm of Hg respectively
and Mean post readings at the time of
examination for Pulse rate, Systolic Blood
Pressure and Diastolic Blood Pressure were
84.73  11.24 per minute, 124.76  10.41 mm
of Hg, 83.76  8.03 mm of Hg respectively
(Table-4).
Table no. 5 shows that there was highly
significant difference in pulse rate among
boys before and during the time of
examination (p<0.001) in MBBS course and
in girls of both MBBS (p<0.001) and
physiotherapy course (p<0.008). The systolic
blood pressure was found to be highly
significant statistically among boys (p<0.001)
in MBBS course and in girls (p<0.001) of
physiotherapy course. The diastolic blood
pressure also showed highly significant
difference among girls (p<0.006) in MBBS
course and in girls (p<0.001) of physiotherapy
course.
Discussion-The present study showed that
there was significant difference in vital
parameters (Pulse rate, Systolic Blood
Pressure and Diastolic Blood Pressure) during
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ACADEMIC STRESS DUE TO DEPRESSION AMONG MEDICAL ……..
academic examination. It was also observed
that the depression level as indicated by
Zung’s self-rating depression scale was very
high [19].The girls had more depression as
compared to boys. A recent research reported
similar findings by [11] Mohsin S. et al.
(2010) that the overall mean perceived stress
was significantly higher among female
students and a higher level of perceived stress
was reported by the students but with the
contrast that stress was not found to differ
significantly on the basis of sex as reported by
[21] Supe AN (1998). Recently, the study [22]
revealed that the depression and stress were
found even in adolescent age. Further, the
findings of study revealed that during
adolescent period they undergo various
stresses and adjustment and it depends upon
their ability to cope with stress in various
places like home, school, peers and teachers
[22]. Girls had more stress as compared to
boys and academics and examinations are
the most powerful stressors in medical
students observed by Sharma BK et al.
(2011) [23].
The prevalence of anxiety is much higher than
either depression or stress, with some
differences in their findings correlates except
for age among university students, opined by
[24] Khadijah S et al. (2013). Various studies
[25] Shah C et al. (2009), [10] Reem Rachel A
(2009) and [21] Supe AN (1998) confirmed
the general impression that there is a
considerable amount of stress among medical
students which is common and process
oriented. Earlier, there have been a number of
studies of the prevalence of depression in
university students worldwide [26-30].
However, different studies used different
assessments. Recently, [31] Chen L et al.
(2013) found that major depressive disorder
was seen in 4.0% of Chinese university
students. In a study based on stress among
physiotherapy students conducted by [32]
Fazaila Sabih et al. (2013) highlighted the
Journal of Health Sciences (J of H Ss) 2013; 3(5)
higher level of stress in undergraduate
physiotherapy students.
Moreover, [33] Steenberger et al. (1993) and
[34] Ronald BW (1993) opined that girls have
reported exams, as the reason for their stress
than their male colleagues. [35] Mamoza MA
(2008) obtained the response of stress by
confirming the higher prevalence of stress in
undergraduate medical students. It was
observed by [36] Everly GS and Rosenfeld R
(1981) that stress is a psycho-physiologic
arousal occurring in the body as a result of a
stimulus which becomes a “stressor” by virtue
of the cognitive interpretation of the
individual.
The study showed the impact of stress and
depression and the authors; [3] Mannapur B et
al. (2010) observed that the students with
psychological stress were found to be
involved in habits like tobacco chewing and
smoking, as well as alcohol intake. Average
stress of the professional group is significantly
higher then non-professional group of students
reflected in the study conducted by [37] Singh
A and Singh S (2008). The prevalence of
perceived stress seems to be high among
medical students, which tends to affect not
only their academic performances but also all
aspects of health and the frequency of stress
seems considerable with little difference
between males and females observed by
[38] Babar TS et al. (2004) which correlates
with the present study.
Furthermore, the academic examinations in
Medical and Para-medical students are found
to be stressful due to high levels of depression
followed by significant changes in vital
parameters which may affect their academic
performances. The study conducted by [39]
Sajjan K and Krupa J (2005) confirms the
general impression that there is considerable
amount of stress found among the
occupational therapy students.
Page 33
ACADEMIC STRESS DUE TO DEPRESSION AMONG MEDICAL ……..

Summary of the findings: The study
reflected that level of depression was more in
girls as compared to boys. The main stressor
was related to academic examinations. An
attempt has been made to identify the
depression and related stress profile of final
year medical and physiotherapy students at the
time of academic examinations. As it is
confirmed the general impression that there is
a considerable amount of depression which
leads to stress and produces changes in vital
parameters in final year Medical and Para-
medical students and it is common and
process oriented.
Limitations of the study: Authors
acknowledge that this is a study with sample
of only final year Medical and Para-medical
students appearing for university examination
drawn from only one medical college.
Furthermore, the findings of this study are
based on self reported information provided
by students and some potential for reporting
bias may have occurred because of student’s
interpretation of the questions or simply
because of inaccuracies of responses or desire
to report their emotions in a certain way. It
could be considered as one of the limitation of
this study. A prospective study could be
carried out with a cohort of all year students in
all the medical and paramedical colleges in the
territory of Madhya Pradesh to look at the
different levels of academic stress related to
depression.
Implications of the study: A high depression
level may affect not only academic
performances but also all aspects of student
physical health. The stressors should be
identified and discussed with individual
students. As depression which impacted these
stress in colleges cannot be eliminated. It is
worth advisable that teachers can and should
do a better job and provide review of
academics and exam schedules, more leisure
time activities, better interaction with the
faculty and proper guidance, advisory services
and peer counseling could do a lot to reduce
the depression. Interventions like reduction of
levels of depression, perceived by students
approaching exam can be planned while
laying more emphasis on regular, day by day
reading, mock examinations and use of
question banks could alleviate the fear,
depression and anxieties associated with the
university examination.

Conflict of Interest: None

Abbreviation: PR-Pulse Rate, SBP- Systolic Blood Pressure, DBP-Diastolic Blood Pressure and
SDS-Standardized Depression Scale
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author(s) and source are credited.

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Table-1: Sex-wise distribution of students according to weight and height

MBBS Physiotherapy
Parameter Variable
Boys Girls Boys Girls
35 -55 1 (2.6) 13 (38.2) 3 (75.0) 18 (32.1)

Weight of Student 56-75 25 (65.8) 19 (55.9) 1 (25.0) 33 (58.9)

(Kilograms) ≥75 12 (31.6) 2 (5.9) 0 (0.0) 5 (8.9)
TOTAL 38 (100.0) 34 (100.0) 4 (100.0) 56 (100.0)
140-160 0 (0.0) 14 (41.2) 0 (0.0) 39 (69.6)
161-180 27 (71.1) 19 (55.9) 3 (75.0) 17 (30.4)
Height of Student
(Centimeters) ≥180 11 (28.9) 1 (2.9) 1 (25.0) 0 (0.0)
TOTAL 38 (100.0) 34 (100.0) 4 (100.0)* 56 (100.0)
*
The figure in parenthesis denotes the corresponding percentage.

Table-2: Sex-wise distribution of students according to according to Body Mass Index

MBBS Physiotherapy
Variable
Boys Girls Boys Girls
<18.5 1 (2.6) 8 (23.5) 0 (0.0) 5 (8.9)
18.5-24.9 26 (68.4) 20 (58.8) 2 (50.0) 29 (51.8)
25-29.9 11 (28.9) 6 (17.6) 2 (50.0) 17 (30.4)
≥30 0 (0.0) 0 (0.0) 0 (0.0) 5 (8.9)
*
TOTAL 38 (100.0) 34 (100.0) 4 (100.0) 56 (100.0)
*
The figure in parenthesis denotes the corresponding percentage

Table-3: Sex-wise distribution of students according to according to depression

Level of Stress MBBS Physiotherapy

Journal of Health Sciences (J of H Ss) 2013; 3(5) Page 36

ACADEMIC STRESS DUE TO DEPRESSION AMONG MEDICAL ……..
SDS INDEX Boys Girls Boys Girls
<50 7 (18.4) 12 (35.3) 0 (0.0) 14 (25.0)
51-59.9 23 (60.5) 9 (26.5) 3 (75.0) 17 (30.4)
60-69.9 5 (13.2) 9 (26.5) 1 (25.0) 19 (33.9)
≥70 3 (7.9) 4 (11.8) 0 (0.0) 6 (10.7)
TOTAL 38 (100.0) 34 (100.0) 4 (100.0)* 56 (100.0)
*
The figure in parenthesis denotes the corresponding percentage.

Table-4: Comparison between Pulse rate, Systolic Blood Pressure and Diastolic Blood Pressure before and at
the time of examination
Before At the time of Mean
Parameters p LOS
examination examination Difference

Pulse rate 77.52  7.75 84.73  11.24 7.21  3.49 7.86 P<0.001


Systolic Blood Pressure 120.29  9.66 124.76  10.41 4.47  0.75 5.39 P<0.001


Diastolic Blood Pressure 81.07  8.71 83.76  8.03 2.69  0.68 3.92 P<0.001



The mean difference is highly significant at the 0.001 level for 131 degrees of freedom. [LOS-Level of
Significance]

Table-5 : Sex-wise comparison between Pulse rate, Systolic Blood Pressure and Diastolic Blood Pressure
before and at the time of examination
Course Sex
Before At the time of
Parameters p LOS
examination examination

MBBS M 78.47  8.75 87.84  10.55 5.94 p<0.001



Physiotherapy M 79.75  4.11 82.25  3.86 1.89 p>0.05*

Pulse rate
MBBS F 76.41  8.15 90.94  13.60 6.23 p<0.001


Physiotherapy F 77.39  6.99 79.04  7.11 2.73 p<0.008



MBBS M 118.97  9.93 127.63  11.78 4.63 p<0.001



Systolic Blood Physiotherapy M 126.25  11.82 128.75  8.54 0.78 p>0.05*

Pressure MBBS F 115.59  10.00 117.94  10.37 1.19 p>0.05*
Physiotherapy F 123.61  7.72 126.66  7.56 4.37 p<0.001


MBBS M 80.11  6.38 82.18  9.98 1.31 p>0.05*

Diastolic Blood Physiotherapy M 88.00  5.48 85.75  5.44 0.59 p>0.05*

Pressure MBBS F 74.03  10.24 78.82  7.10 2.97 p<0.006


Physiotherapy F 85.50  5.83 87.68  4.69 3.46 p<0.001




The mean difference is highly significant at the 0.001, 0.006 and 0.008 levels of significance. * The mean
difference isn’t significant (insignificant) at the 0.05 level. [LOS-Level of Significance]
This is an open access article licensed under the terms of the Creative Commons Attribution Non
Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted, non commercial
use, distribution and reproduction in any medium, provided the work is properly cited.

Journal of Health Sciences (J of H Ss) 2013; 3(5) Page 37

ACADEMIC STRESS DUE TO DEPRESSION AMONG MEDICAL ……..

Conflict of interest: None declared.

Received: 15.02.2013.
Revised: 15.03.2013.
Accepted: 19.05.2013.

Correspondence to:-Dr. Balkishan Sharma, Ph. D., Dept. of Community Medicine, Sri Aurobindo Medical College
and P. G. Institute, Indore, (M. P.) India. Mob: 9926049820, Fax:(0731) 4231010 E-mail :
bksnew@rediffmail.com

Journal of Health Sciences (J of H Ss) 2013; 3(5) Page 38