|Year : 2015 | Volume
| Issue : 2 | Page : 119-123
A study of stress, anxiety, and depression among postgraduate medical students
Anjali N Shete1, KD Garkal2
1 Department of Physiology, Government Medical College, Aurangabad, India
2 Registrar, Maharashtra University of Health Sciences, Nashik, Maharashtra, India
|Date of Web Publication||16-Mar-2015|
Anjali N Shete
Department of Physiology, Government Medical College, Aurangabad, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Medical education is highly challenging and often places heavy demands on the mental health of the students. Stress is an external constraint which upsets an individual both mentally and physically. The postgraduate students suffer from higher stress that definitely affects the mental wellbeing of these students. Study Design: It is a cross-sectional, observational study. Objectives: The objective of the present study was to explore the level of stress, anxiety and depression among the postgraduate medical students. The secondary objective was to find out the factors affecting the stress, anxiety and depression level in these students. Materials and Methods: Fifty post graduate medical students of Government Medical College were selected. Depression, anxiety and stress scale 42 questionnaires were given for assessment of stress level. A completed scale was taken for assessment from the students. Result: The mean depression score was 6.26 ± 6.00, the anxiety score was 10.34 ± 3.91 and the mean stress score was 15.30 ± 3.93. The present study showed mild anxiety level and moderate level of stress in postgraduate students. The study showed a difference in stress level when compared for age and gender, but it was not statistically significant. When the stress level was compared for clinical and non-clinical departments; the difference was statistically significant. Conclusion: The present study concluded that a high level of stress is seen in postgraduate medical students. The study further concluded that there are various factors which can affect the level of stress. These factors should be assessed separately for the further study.
Keywords: Anxiety and stress scale 42, depression, stress anxiety depression, postgraduate medical students
|How to cite this article:|
Shete AN, Garkal K D. A study of stress, anxiety, and depression among postgraduate medical students. CHRISMED J Health Res 2015;2:119-23
|How to cite this URL:|
Shete AN, Garkal K D. A study of stress, anxiety, and depression among postgraduate medical students. CHRISMED J Health Res [serial online] 2015 [cited 2017 Sep 24];2:119-23. Available from: http://www.cjhr.org/text.asp?2015/2/2/119/153255
| Introduction|| |
Stress is a state of an individual that results from the interaction of the individual with the environment that is perceived as threatening to the well-being. It is an external constraint which directly upsets the individual both mentally and physically.  Individual in a stressful situation is influenced by his or her mental ability to carry out ongoing tasks. , Medical education is highly challenging and often places heavy demands on the mental resources of its students; stretching their psychological distress and making them vulnerable to high levels of negative affective states. Compared to other education; medical education is evidenced by high prevalence of stress.  Several studies have revealed that the incidence of stress and stress related illness such as anxiety and depression among the medical profession are increasing day by day. Educational process exerts an inadvertent negative effect on student's mental health with a high frequency of depression, anxiety and stress among medical students. ,,,
The three main stressors identified are examinations, work and financial responsibilities. Several other factors such as curriculum, traumatic events related to patients, ethical dilemmas also make them vulnerable to depression.  Gender, lack of family support, are also one of the risk factors.  Students exposed to work overload in a competitive environment with constant pressure of assessment brings various changes in their daily habits such as lack of sleep, irregular diet, substance abuse. 
There are very few studies in this context in India and very few in Maharashtra. Keeping all these factors in mind; the present study was planned to describe findings of stress among postgraduate students of Government Medical College. It is a pilot study to see the prevalence of stress and related depression and anxiety among these students.
| Materials and methods|| |
Fifty post-graduate students of both sex studying at Government Medical College, were selected. Thorough clinical history and examination was done. The students are having any major disorder or with recent history of any incidence affecting his/her mental health were excluded. The details included age, gender, H/O medications were recorded. A written consent was taken and complete confidentiality was assured. A questionnaire depression, anxiety and stress scale 42 (DASS 42) was given to each participant along with a standard preface explaining the purpose of the study and was asked to fill. The DASS 42 scale described by Lovibond and Lovibond  is a survey that measures the level of depression, anxiety and stress levels in an individual.
The structure of the DASS is similar to the tripartite model of Clark and Watson  which conceptualizes depression and anxiety as having unique distinguishing features and some common symptoms as well. During the testing of the scale, a new factor emerged that referred to the difficulty in relaxing, nervous tension, irritability and agitation. This difficulty was labeled as "Stress" by virtue of perceived similarity to the symptoms of tension or stress described. The DASS 42 has 14 items for each of the three scales. Items 3, 5, 10, 13, 16, 17, 21, 24, 26, 31, 34, 37, 38 and 42 form the depression scale and assess dysphoria, hopelessness, deviation of life, self-deprecation, lack of interest or involvement and inertia. The anxiety scale has 14 items; 2, 4, 7, 9, 15, 19, 20, 23, 25, 28, 30, 36, 40 and 41 which measures autonomic arousal, skeletal stress scale has items 1, 6, 8, 11, 12, 14, 18, 22, 27, 29, 32, 33, 35 and 39 which quantifies the difficulty in relaxing, nervous arousal and being easily upset or agitated or irritable. The respondents rate the extent to which they have experienced the symptoms over the previous week on a four-point rating scale. The sum of scores obtained from the 14 items in each scale and the scale severity is interpreted as shown in [Table 1].
The scale has been tested and found to possess excellent reliability, good validity and simple in language and required less time. 
The data were analyzed and coded. The variables such as age, gender and working department (clinical or non-clinical) were assessed. The variables were compared and Chi-square test was applied for statistical significance. P = 0.0001.
| Results|| |
A total of 50 completed questionnaires were returned. The age of the participants ranged from 23 to 34 years. Among 50 participants; 17 were males and 33 were females. Totally 25 students were from Pre-clinical Departments and 25 were from Clinical Departments. When we analyzed, the depression scale, among total of 50 participants; 40 reported no evidence of depression. Six cases showed mild depression, one moderate depression; three were having severe depression and one case showed extreme depression. The mean depression score was found to be 6.26 ± 6.00. [Table 2] showing overall DASS score. The anxiety scale reported 10 normal interpretation. Among the remaining participants, 18 showed mild anxiety, 16 moderate and three severe anxiety status. Three cases reported extreme severe anxiety status. The mean anxiety score was found to be 10.34 ± 3.91.
The study reported 24 normal cases for stress scale. 15 were having mild stress, 10 were moderate stress and one case reported severe stress score. No case showed extreme severe stress level. The mean stress score was 15.30 ± 3.93. For the overall sample, the level of depression was found to be in normal range [Table 2]. The results showed a moderately higher level of anxiety and mild degree of stress level in post graduate students.
We further grouped the sample into different groups to observe the correlation of factors on the stress level in post-graduate students. The data was grouped into three types; age, gender and type of department in which he or she works [Table 2],[Table 3] and [Table 4]. The depression score in males was 7.17 ± 7.70 and in females was 5.66 ± 5.08. The depression score in age group 23-28 years was 6.82 ± 6.50 and in group of 29-34 years was 5.36 ± 5.18. The depression score in preclinical students was 2.80 ± 3.09 and in clinical students it was 9.56 ± 6.46. The results were statistically significant for type of departments. The anxiety score for males was 9.76 ± 3.63 and for females was 10.63 ± 4.06. For age 23-28 years it was 10.53 ± 3.97 and for age 29-32 years it was 10.09 ± 3.90. For preclinical departments it was 8.621 ± 49 and for clinical departments it was 12.00 ± 4.82. The results were statistically significant for department difference. The stress score for males was 14.05 ± 3.09 and for females was 16.24 ± 4.27. The score in age group 23-28 years was 16.28 ± 4.31 and for age group 29-32 years it was 13.86 ± 2.94. The preclinical departments showed a stress score of 12.88 ± 2.33 and clinical departments showed a score of 18.12 ± 3.63. The results were significant for department category only. All the selected candidates were of 1 st year of postgraduation and similar socio economic status. These variables, therefore, were not compared.
| Discussion|| |
Medical students are expected to learn and master a huge amount of knowledge, attitudes and skills for which they have to work hard which in turn put them under a lot of stress.  Studies of medical students from Saudi Arabia, Malaysia, Thailand identified a high frequency of stress. ,, The present study also showed a high-stress level in post graduate medical students. The anxiety level in our study was higher. However, the depression level was found to be in normal range in the present study [Table 2].
Our study showed no significant correlation for the gender difference [Table 3]. It may be due to small and unequal sample size. Studies by Salam et al.  showed a higher prevalence of stress among female students that were not statistically significant. Similar findings were shown by Amar et al.  and Baldassin et al. The present study showed a higher stress level in younger age group compared to elder group. The results were not statistically significant. Similar findings were shown by Johari et al.  The younger age group shows a higher stress level which may be due to a new level of responsibility, increased workload in addition to education and patient care activities [Table 4].
Our study revealed a significant difference in stress level between clinical and nonclinical departments students [Table 5]. It may be due to extended duty hours, increased workload and dealing with patient related issues like emergency situations, trauma cases and death, etc., The other stressors may initiate the stress response of sympathetic nervous system. In response to the stressors; corticotrophin releasing hormone, arginine, vasopressin and adrenal medullary hormones are released at higher concentration. And it probably changes the ratio of acetylcholine, adrenaline and serotonin that gives a higher stress score.
Extensive course, training programs and examinations are a major cause of distress among medical students. Student's distress influences the professional development and affects the academic performances. Distressed students show decay in humanatarian attitudes  and decline in empathy.  Medical students are the future doctors who are the caregivers for the physical and mental wellbeing of the patients. To ensure the patient safety and well-being, it is very essential to focus on the mental health of the future doctors. Curriculum planners need to give proper attention to take appropriate measures to reduce the stress among these students.
Hernandez et al.  mentioned that it is a challenge for the educators to convert the effects of stress as a learning stimulus instead of eliminating it. Acute stress has some beneficial effects but, when stress is excessive it leads to deterioration of physical and mental health. In considering the preventing measures it is important to address both primary and secondary prevention. Primary prevention aims to enhance mental health literacy and psychological well-being by providing workshops on time management, stress management, relaxation training, etc., Secondary prevention measures the target at risk group such that help and support can be provided in a timely and proactive manner to further impairment.  Supportive, nonthreatening educational environment in the institution can help to cope up the extensive course of the medical curricula. An enhanced structuring of the clinical training may also be helpful. Medicine is a profession which requires a high standards of behavior.  Informal peer, faculty and professional support programs are essential to mitigate the effects of perceived stress. Areas like difficult patient encounters, practice management that are directly related to professional stress should be given due curricular importance.
| Conclusion|| |
The medical education and training are highly stressful. Our study revealed a raised level of anxiety and stress among the post graduate students. There are factors such as age and type, of course, which enhances further the anxiety and stress level among these students.
| Limitations|| |
As it was a questionnaire-based study, the response made by the residents may not be true information. The data were collected randomly and not at a particular time. Hence, the students may not be in similar mental state which could have affected the findings of the study. Proportionate sampling was not done, sample size was small only including one government medical college which might have affected the results of our study. So, further studies with more sample size using multivariate techniques are to be planned.
| References|| |
Salam A, Yousuf R, Bakar SM, Haque M. A systematic review of literatures. Int Med J 2013;20:649-55.
Aris SM, Marium AD. Differences in depression, anxiety and stress between low and high achieving students; J Sustain Sci Manage 2011;6:169-78.
Khodarahimi S, Hashmi IH, Zaharim NM. Perceived stress, positive-negative emotions, personal values and perceived social support in Malaysian undergraduate students. Int J Psychol Bahav Sci 2012;2:1-8.
Jeong Y, Kim JY, Ryu JS, Kei L, Ha EH, Park H. The associations between social support, health related behaviours, socioeconomic status and depression in medical students; Epidemiol Health 2010;32.
Stewart SM,Betson C,Marshall I,Wong CM,Lee PW,Lam TH. Stress and vulnerability in medical students. Med Edu 1995;38:479-81.
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.
Saipanish R. Stress among medical students in a Thai medical school. Med Teach 2003;25:502-6.
Singh G, Hankins M, Weinman JA. Does medical school cause health anxiety and worry in medical students? Med Educ 2004;38:479-81.
Baldassin S, Alves TC, de Andrade AG, Nogueira Martins LA. The characteristics of depressive symptoms in medical students during medical education and training: A cross-sectional study. BMC Med Educ 2008 11;8:60.
Saharaian A, Javadpour A. Sleep disruption and it′s correlation to pscychological distress among medical students. Shiraz E Med J 2010;11:12-7.
Lovibond LH, Lovibond PF. Manual for the Depression, Anxiety, Stress Scales. 2 nd
ed. Sydney: Psychology Foundation of Australia; 1995.
Clark LA, Watson D. Tripartite model of anxiety and depression: Psychometric evidence and taxonomic implications. J Abnorm Psychol 1991;100:316-36.
Wolf TM, Kissling GE. Changes in life-style characteristics, health, and mood of freshman medical students. J Med Educ 1984;59:806-14.
Abdulghani HM, AlKanhal AA, Mahmoud ES, Ponnamperuma GG, Alfaris EA. Stress and its effects on medical students: A cross-sectional study at a college of medicine in Saudi Arabia. J Health Popul Nutr 2011;29:516-22.
Mannapur B, Dorle AS,Hiremath ID, Ghattargi CH, Ramadurg U,Kulkarni KR. A study of psychological stress in undergraduate medical college students at S.N. medical college, Bagalkot, Karnataka. J Clin Diagn Res 2010;4:2869-74.
Amr M, Hady El Gilany A, El-Hawary A. Does gender predict medical students′ stress in mansoura, egypt? Med Educ Online 2008;13:12.
Johari AB, Hassim IN. Stress and coping strategies among medical students in national university of Sabah and university Kualalumpur Royal college of Medicine. J Community Health 2009;15:106-15.
Griffith CH, Wilson JF. The loss of idealism throughout internship. Eval Health Prof 2003;26:415-26.
Hojat M, Mangione S, Nasca TJ, Rattner S, Erdmann JB, Gonnella JS, et al
. An empirical study of decline in empathy in medical school. Med Educ 2004;38:934-41.
Hernandez MB, Blavo C,Hardigan PC,Perez AM,Hage K. Differences in perceived stress depression and medical symptoms among medical, nursing and physician assistant students, a latent class analysis. Ann Behav Sci Med Educ 2010;16:35-9.
Wong JG. Doctors and stress, the Hongkong medical Diary. Med Bull 2008;13:4-7.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]