|
 
 |
| EDITORIAL |
|
| Year : 2022 | Volume
: 27
| Issue : 2 | Page : 71-74 |
|
Mental health issues among medical students
Sandeep Grover
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012, India
| Date of Submission | 20-Dec-2022 |
| Date of Decision | 23-Dec-2022 |
| Date of Acceptance | 25-Dec-2022 |
| Date of Web Publication | 13-Jan-2023 |
Correspondence Address:
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jmhhb.jmhhb_297_22
How to cite this article:
Grover S. Mental health issues among medical students. J Mental Health Hum Behav 2022;27:71-4 |
The medical profession is considered a Nobel, and in today's scenario, a significantly large proportion of adolescents aspire to become doctors in a country like India. The data from India suggest that the number of aspirants who want to become doctors is increasing yearly. Compared to 5.8 lakh aspirants in 2014, the number of aspirants increased to 18.7 lakh in 2022. In 2022, about 10 lakh of students qualified.[1] In 2021, there were about 82,000 seats for MBBS in India, and as per recent data, there are 98,463 MBBS seats across 650 colleges.[2] In addition, about 28,000 BDS seats in India are spread over more than 300 dental colleges. It is also well known that many students from India go to countries like China, Ukraine, Russia, Philippines, etc., to pursue undergraduate medical courses.[3] Considering the number of students who appear and qualify for these courses, there is tough competition for joining these courses, and the students undergo severe stress while preparing for the entrance examination.
A survey of medical students from India showed that 8% of the students consulted a mental health professionals (MHPs) before joining the medical courses, and 2% were diagnosed with a mental disorder, such as mood disorder, anxiety disorder, adjustment disorder, obsessive-compulsive disorder, and attention deficit hyperactivity disorder.[4] A recent analysis of media reports showed that some of the National Eligibility Entrance Test (NEET) aspirants ended their life.[5] These limited data suggest that many students go through stress during the preparation for the NEET and have adverse mental health outcomes.
Once the students qualify for the medical courses, it brings in a lot of joy and happiness and marks the beginning of a new era in their life, possibly with little understanding about what is in store in the future. However, joining the undergraduate medical courses for a significant proportion of students involves moving away from home for the first time. A proportion of them also must adjust to the new environment away from home, new food, education in English, and ragging. The young adolescents also have to deal with the newly found freedom and peer pressure for using substances and relationship issues. Other issues which could act as drivers of stress include competitiveness, the pressure of studies, and meeting the expectations of parents and teachers. In recent years, there is also a trend of starting preparation for postgraduate courses as early as the 3rd year of the undergraduate course. Preparing for the next competitive examination also brings additional stress.
However, more needs to be understood about the mental health issues of undergraduate medical students. This editorial attempts to examine the mental health issues in undergraduate medical students, and an attempt is made to evaluate the suggested methods for reducing mental health stress among medical students.
When one looks at the psychological issues evaluated among undergraduate medical students in one or more studies, these have mainly focused on depression. Other problems assessed in different studies include anxiety, stress, physician burnout, substance use disorders, insomnia, eating problems, and behavioral or Internet addiction.
A systematic review and meta-analysis of 41 studies (n = 36,608) from different parts of the globe reported the pooled prevalence of depression to be 37.9% (95% confidence interval [CI]: 30.7%–45.4%). This review also showed that the prevalence of depression was influenced by the assessment instrument.[6] In terms of country, the highest prevalence of depression was noted among the Spanish medical students (86.0%, 95% CI: 80.9%–90.1%), whereas students from Japan (15.9%, 95% CI: 12.7%–19.5%) had a much lower prevalence of depression compared to students from other countries.[6] Another systematic review of data from 40 studies on depression among undergraduate medical students from the United States of America and Canada suggests that there is wide variation in the prevalence of depression that is influenced by the study instrument and assessment time during the undergraduate course. The data indicate that the prevalence of depression is consistently higher among medical students than among the general population. Some of the longitudinal studies also suggest that the prevalence of depression at the end of the 1st year is higher than at the time of entry into medical school, and depression scores peak in the 2nd year and then remain high throughout the course.[7] The reviews that focused on studies from Asia and China reported the prevalence of depression to be 11% and 29%, respectively.[8],[9] In terms of factors associated with depression, data suggest that prevalence is higher among females when compared to males.[6]
The systematic review of data from different parts of the world suggests that the pooled prevalence of anxiety among medical students is 33.7% (95% CI: 26.8%–41.1%), with the highest prevalence among students from Bangladesh (65.9%, 95% CI: 61.2%–70.4%).[6] The systematic review of data from Asia and China has estimated the same to be 7.04% and 21%, respectively.[8],[9] Studies from China have reported the prevalence of suicidal ideations to be 11%.[8]
Physician burnout is defined as long-term stress and by three subcomponents, i.e., emotional exhaustion, depersonalization, and a sense of reduced personal achievement. Few systematic reviews and meta-analyses report the prevalence of burnout among medical students. A systematic review and meta-analysis of the available data reported the mean prevalence of emotional exhaustion, depersonalization, and reduced personal achievement to be 22.93%, 8.88%, and 35.11%, respectively, with significantly higher prevalence, compared to the normative data for the burnout among the postsecondary education students.[10] Two other systematic reviews and meta-analyses reported the prevalence of overall burnout to be 37.23 % (95% CI: 32.66%–42.05%)–44.2% (95% CI: 33.4%–55.0%) and that of emotional exhaustion to be 38.08% (95% CI: 30.67%–46.10%)–40.8% (95% CI: 32.8%–48.9%). The prevalence of depersonalization is 35.1% (95% CI: 27.2%–43.0%)–36.85% (95% CI: 30.67%–46.1%), and that of personal achievement ranges from 27.4% (95% CI: 20.5%–34.3%)–35.07% (95% CI: 32.66%–42.05%).[11],[12] Regarding country variance, the highest prevalence was noted in Oceania and the Middle East than in other continents; however, there was no significant difference between the two genders.[11]
Eating behavior/disorder has also been a commonly evaluated psychological outcome among medical students. A random-effects meta-analysis reported the pooled prevalence of feeding and eating disorders to be 17.35% (95% CI: 14.15%–21.10%).[13] A surprising finding was that the prevalence was significantly higher in nonWestern cultures than in the Western culture.[13]
The Internet has now become part of the daily life of human beings. A meta-analysis of available studies on Internet addiction among medical students suggested that the pooled prevalence rate is 30.1% (95% CI: 28.5%–31.8%), with most of the studies relying on the Young Internet Addiction Test.[14]
| What Does the Data from India Suggests | |  |
There are some data from India on the prevalence of various psychological outcomes among medical students. A meta-analysis based on the random effect model estimated the pooled prevalence of depression to be 40% (CI: 32%–47%).[15] Recent studies have estimated the prevalence of anxiety disorder to be 20.2%–40.1%,[16],[17] and the risk for suicidal behavior was estimated to be 29.6%.[17] Regarding eating disorders or behavior, a review of seven studies reported the prevalence of eating distress syndrome to be 11%–14.8%, and the prevalence of disordered eating behavior was 16.9%–29.2%.[18] One of the studies reported the prevalence of stress among medical students to be 43.8%.[16] Based on this evidence, it can be said that data from India is also in line with the other parts of the globe.
| What are the Factors Associated With Adverse Psychological Outcomes Among Medical Students? | | |
Studies from different parts of the globe suggest that the prevalence of depression, anxiety, and general distress is higher among females when compared to males.[7] Some of the data also suggest that adverse psychological outcomes are more common among those who are single (compared to those who are married) and females with children (compared to females without children).[7] Data also suggest that a higher perception of stress is associated with higher rates of depression, anxiety, somatic symptoms, and health problems.[7] In terms of personality, traits of maladaptive perfectionism, socially prescribed perfectionism (perception that others expect a great deal of you), Type A personality, and anger suppression have been linked to a higher risk of depression. On the other hand, traits of self-actualization, self-awareness, and a sense of fulfillment have been reported to be associated with a lower risk of depression.[7] With regard to coping higher risk of depression has been reported to be associated with the use of disengagement strategies, such as problem avoidance and social withdrawal.[7] In terms of the medical career stage, a review suggests that the prevalence of depression is 1.63 times higher among preclinical students compared to clinical students.[9] Another interesting fact noted in a review was that the prevalence of depression was 1.33 times higher among those staying at home compared to those staying in a hostel.[9]
Data from India also suggest that depression is more common among females, among those who compare themselves negatively with their peers/friends and are addicted to smartphones.[15],[19]
| Barriers to Seeking Mental Health Care | | |
Although adverse psychological outcomes are highly prevalent among medical students, they usually do not seek help. The commonly identified reasons for not seeking help include perceived stigma, misunderstanding about fitness to practice procedures, apprehension about career progression, and peer comparison.[20],[21],[22],[23],[24]
Data from India suggest that medical students generally prefer informal consultations and self-diagnosis due to concerns about confidentiality. Further, it is noted that students with psychiatric disorders perceive more barriers to seeking mental health care than students without psychiatric disorders.[17] A study comparing the barriers to help seeking in students from India and Thailand found that a lower proportion of medical students from Thailand (66%) sought help when compared to those from India (81%). When the factors associated with avoidance of help seeking were evaluated, the risk factors in students from Thailand included the presence of history of alcohol use (odds ratio [OR] = 1.88, P = 0.014) and higher total General Health Questionnaire (GHQ) score (OR = 1.11, P = 0.006), whereas in India, only GHQ score ≥ 2 (OR = 2.20, P = 0.044) was associated with poor help seeking. The attitude toward mental illness did not influence help seeking from MHPs. The factors related to seeking help from MHPs (in Thailand but not in India) included being diagnosed with mental illness and having a family member or a friend who had sought treatment from MHPs.[25]
| What Can Be Done to Improve The Mental Health Outcomes Of Medical Students? | | |
Different interventions have been proposed and evaluated to improve the mental health outcomes of medical students. Some of these interventions focus on improving access to mental health providers, reducing the stigma associated with mental illnesses and mental health treatment, and implementing wellness programs. Other interventions target the educational system and include having a pass–fail system (rather than a grading system that brings in more competitiveness and resultant mental distress) and providing clear learning objectives to the students (as this allows the students to focus on them and also motivates them to achieve those objectives). Many different teaching methods, such as small group activities, team-based learning, reflective learning, flipped classes, and problem-based learning, have been reported to be associated with better learning and lower level of stress. Further, providing an engaging curriculum that can offer different styles, for example, small group tutorials, team-based learning, and flipped classes, have been reported to be associated with lower stress levels.[26],[27]
Similarly, having prescheduled examinations with proper gaps between different subjects, providing adequate time off between their clinical rotations so that the students can relax, and promoting reflective activities (such as reflective diaries and portfolios throughout the curriculum and timely and constructive feedback) have also been reported to be associated with reduced stress. An early introduction to clinical medicine has been suggested so that students can easily relate theory to practice. Besides focusing on the core curriculum, measures such as conducting longitudinal workshops or modules on communication skills, stress management, learning about work–life balance and providing opportunities for extracurricular activities to students, and encouraging them to improve their well-being with regular physical exercise and sufficient sleep can also be helpful. In addition, the inclusion of elements of professionalism in the core curriculum has also been suggested.[26],[27]
Different wellness programs have also been designed to improve the mental health outcomes of medical students.[28] The wellness programs emphasize the involvement of faculty and administrators to improve wellness of the students by facilitating safe environment in which the student can feel safe to open up about their mental health concerns and seek the desired support. For these wellness programs, training sessions for the faculty should be done and student liaison committees must be developed.[28]
| Conclusion | | |
There is a high level of mental stress/distress among medical students, and there is a need to increase awareness about the same among medical teachers. There is also an urgent need to develop mental health services for the students and increase their awareness about the benefits. With the expansion of telepsychiatry services across various institutes, these services can be offered through Telemode, which may possibly increase the acceptability of mental health consultation. Further, mental health services can be provided on the hostel premises, which may remove the stigma associated with psychiatry outpatient services. The educational system in India has undergone certain modifications in recent times, still, there is a need to modify the teaching methods to improve learning and reduce stress.
| References | | |
| 1. | |
| 2. | |
| 3. | |
| 4. | Philip S, Molodynski A, Barklie L, Bhugra D, Chaturvedi SK. Psychological well-being and burnout amongst medical students in India: A report from a nationally accessible survey. Middle East Curr Psychiatry 2021;28:54.  |
| 5. | Kar SK, Rai S, Sharma N, Singh A. Student suicide linked to NEET examination in India: A media report analysis study. Indian J Psychol Med 2021;43:183-5. |
| 6. | Jia Q, Qu Y, Sun H, Huo H, Yin H, You D. Mental health among medical students during COVID-19: A systematic review and meta-analysis. Front Psychol 2022;13:846789. |
| 7. | Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad Med 2006;81:354-73. |
| 8. | Zeng W, Chen R, Wang X, Zhang Q, Deng W. Prevalence of mental health problems among medical students in China: A meta-analysis. Medicine (Baltimore) 2019;98:e15337. |
| 9. | Cuttilan AN, Sayampanathan AA, Ho RC. Mental health issues amongst medical students in Asia: A systematic review [2000-2015]. Ann Transl Med 2016;4:72. |
| 10. | Erschens R, Keifenheim KE, Herrmann-Werner A, Loda T, Schwille-Kiuntke J, Bugaj TJ, et al. Professional burnout among medical students: Systematic literature review and meta-analysis. Med Teach 2019;41:172-83. |
| 11. | Frajerman A, Morvan Y, Krebs MO, Gorwood P, Chaumette B. Burnout in medical students before residency: A systematic review and meta-analysis. Eur Psychiatry 2019;55:36-42. |
| 12. | Almutairi H, Alsubaiei A, Abduljawad S, Alshatti A, Fekih-Romdhane F, Husni M, et al. Prevalence of burnout in medical students: A systematic review and meta-analysis. Int J Soc Psychiatry 2022;68:1157-70. |
| 13. | Fekih-Romdhane F, Daher-Nashif S, Alhuwailah AH, Al Gahtani HM, Hubail SA, Shuwiekh HA, et al. The prevalence of feeding and eating disorders symptomology in medical students: An updated systematic review, meta-analysis, and meta-regression. Eat Weight Disord 2022;27:1991-2010. |
| 14. | Zhang MW, Lim RB, Lee C, Ho RC. Prevalence of internet addiction in medical students: A Meta-analysis. Acad Psychiatry 2018;42:88-93. |
| 15. | Dwivedi N, Sachdeva S, Taneja N. Depression among medical students of India: Meta-analysis of published research studies using screening instruments. Indian J Soc Psychiatry 2021;37:183-90. [Full text] |
| 16. | Taneja N, Sachdeva S, Dwivedi N. Assessment of depression, anxiety, and stress among medical students enrolled in a medical college of New Delhi, India. Indian J Soc Psychiatry 2018;34:157-62. [Full text] |
| 17. | Arun P, Ramamurthy P, Thilakan P. Indian medical students with depression, anxiety, and suicidal behavior: Why do they not seek treatment? Indian J Psychol Med 2022;44:10-6. |
| 18. | Vaidyanathan S, Kuppili PP, Menon V. Eating disorders: An overview of Indian research. Indian J Psychol Med 2019;41:311-7. [ PUBMED] [Full text] |
| 19. | Solanki HK, Awasthi S, Kaur A, Pamei G. Depression, its correlates and quality of life of undergraduate medical students in the Kumaon region of Uttarakhand State, India. Indian J Community Health 2021;33:357-63. |
| 20. | |
| 21. | Sayburn A. Why medical students' mental health is a taboo subject. Stud BMJ 2015;23:H722. |
| 22. | Slavin SJ. Medical student mental health: Culture, environment, and the need for change. JAMA 2016;316:2195-6. |
| 23. | Chew-Graham CA, Rogers A, Yassin N. 'I wouldn't want it on my CV or their records': Medical students' experiences of help-seeking for mental health problems. Med Educ 2003;37:873-80. |
| 24. | Henderson M. Research into medical student mental health: What is it for, and where might it lead? Med Educ 2016;50:602-4. |
| 25. | Seera G, Arya S, Sethi S, Nimmawitt N, Ratta-Apha W. Help-seeking behaviors for mental health problems in medical students: Studies in Thailand and India. Asian J Psychiatr 2020;54:102453. |
| 26. | Shah SI, Ahmed M. Medical students' anxiety on beginning clinical studies. Al Ameen J Med Sci 2013;6:195-201. |
| 27. | Azim SR. Mental Distress among Medical Students. InchOpen; 2020. |
| 28. | Klein HJ, McCarthy SM. Student wellness trends and interventions in medical education: A narrative review. Humanit Soc Sci Commun 2022;9:92. |
|
Search Pubmed for