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 Table of Contents  
REVIEW ARTICLE
Year : 2017  |  Volume : 22  |  Issue : 2  |  Page : 88-96

A systematic review of depression, anxiety, and stress among medical students in India


1 Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
2 Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Date of Web Publication2-Apr-2018

Correspondence Address:
Siddharth Sarkar
Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmhhb.jmhhb_20_17

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  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


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

How to cite this URL:
Sarkar S, Gupta R, Menon V. A systematic review of depression, anxiety, and stress among medical students in India. J Mental Health Hum Behav [serial online] 2017 [cited 2018 Sep 24];22:88-96. Available from: http://www.jmhhb.org/text.asp?2017/22/2/88/229100




  Introduction Top


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],[7],[8],[9],[10],[11] Systematic reviews have been conducted upon studies reporting anxiety and depression among medical students from different parts of the world.[12],[13],[14] Indian medical education system has some unique features which 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 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 Top


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.

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 Top


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.
Figure 1: Identification and inclusion of the studies

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Forty-five studies were excluded. Nineteen studies were excluded because they did not specifically give the prevalence rate for anxiety/depression/stress.[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36] Thirteen were excluded because they were conference abstracts.[37],[38],[39],[40],[41],[42],[43],[44],[45],[46],[47],[48],[49] Seven dealt with examination-related stress.[50],[51],[52],[53],[54],[55],[56]. Four were not relevant.[57],[58],[59],[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 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].
Table 1: Studies evaluating depression and/or anxiety among medical students

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

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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 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].
Table 2: Studies evaluating stress and mental distress among students

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

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

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  Discussion Top


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 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 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 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 Top


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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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