Study of stress, anxiety, depression, coping, and associated factors among medical students from central India

Vijay Babar; Sachin Ratan Gedam; Sharad Manore; Kedarnath Dewangan; Prafulla Gaikwad; Swapnil Patond

doi:10.4103/jdmimsu.jdmimsu_226_20

ORIGINAL ARTICLE

Year : 2020 | Volume : 15 | Issue : 3 | Page : 391-396

Study of stress, anxiety, depression, coping, and associated factors among medical students from central India

Vijay Babar¹, Sachin Ratan Gedam², Sharad Manore³, Kedarnath Dewangan⁴, Prafulla Gaikwad⁵, Swapnil Patond⁶
¹ Department of PSM, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India
² Department of Psychiatry, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India
³ Department of Psychiatry, BRLSABVM Medical College, Rajnandgaon, Chhattisgarh, India
⁴ Department of Respiratory Medicine, Shri Shankaracharya Institute of Medical Sciences, Bhilai, Chhattisgarh, India
⁵ Department of Oral and Maxillofacial Surgery, Sharad Pawar Dental College, Wardha, Maharashtra, India
⁶ Department of Forensic Medicine, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India

Date of Submission	18-Jun-2020
Date of Decision	30-Jun-2020
Date of Acceptance	30-Jul-2020
Date of Web Publication	1-Feb-2021

Correspondence Address:
Dr. Sachin Ratan Gedam
Department of Psychiatry, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jdmimsu.jdmimsu_226_20

Abstract

Objectives: Previous studies worldwide have reported that medical students are subjected to stress and related psychological morbidities. Stress could lead to psychological problems such as depression and anxiety. The objectives were to estimate the prevalence of depression, anxiety, and stress; to identify sources of stress and coping strategies; and their association with depression, anxiety, and stress scores (Depression, Anxiety and Stress scale (DASSs)). Materials and Methods: this cross-sectional survey was conducted among 2^nd-year MBBS students during June–July 2017 from Jawaharlal Nehru Medical College, Sawangi (Meghe) Wardha, Maharashtra. A total of 169 students were assessed through semi-structured pro forma, Depression, Anxiety and Stress scale (DASS), coping inventory for the stressful situation, and sources of academic stress among students for data collection. Results: The overall prevalences of depression, anxiety, and stress among the students were found to be 60.94%, 73.37%, and 37.27%, respectively. The most common source of stress was found to be academic factors, with coping strategy being task-oriented. A significant association of student's satisfaction with depression and stress; gender with stress; depression with emotion and task-oriented coping strategies; emotion oriented with stress and anxiety; and all stress sources with DASS had been found. Conclusion: The students were subjected to depression, stress, and anxiety. Academic factors were found to be the important stressor. Hence, appropriate strategies need to be conducted to decrease the burden of students.

Keywords: Anxiety, coping strategies, depression, medical students, stress

How to cite this article:
Babar V, Gedam SR, Manore S, Dewangan K, Gaikwad P, Patond S. Study of stress, anxiety, depression, coping, and associated factors among medical students from central India. J Datta Meghe Inst Med Sci Univ 2020;15:391-6

How to cite this URL:
Babar V, Gedam SR, Manore S, Dewangan K, Gaikwad P, Patond S. Study of stress, anxiety, depression, coping, and associated factors among medical students from central India. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2021 Feb 28];15:391-6. Available from: http://www.journaldmims.com/text.asp?2020/15/3/391/308562

Introduction

Stress is the most common and process-oriented obstacle in medical education, which may exert a negative effect on the physical health, academic performance, and psychological well-being of the students.^[1] Previous studies have reported increasing stress and high levels of distress, such as depressive symptoms among medical undergraduates.^{[2],[3],[4],[5]} The factors such as physical, academic, and emotional factors are found to be greater perceived causes of stress among students.^[6] Factors such as age, gender, ethnicity, and marital status influence the severity of stress and academic performance of the students.^[7],[8],[9] Increase stress may affect students' academic achievement; reduce their self-esteem, physical and mental health issues.^[10],[11] Previous studies have classified sources of stress into three main areas: social issues, academic pressures, and financial problems.^[12]

Review of literature reported coping strategies of medical students with stresses of undergraduate education have identified the use of alcohol and other substances such as tobacco and drugs as a coping strategy.^{[13],[14],[15],[16],[17],[18]} Whereas a study from Pakistan reported that music, sports, and hanging out with friends were common coping strategies.^[19] Studies on medical students from developing countries such as India, Pakistan, Thailand, and Malaysia have reported stress among them and have underscored the role of academics as a source of stress.^{[6],[19],[20],[21]} Several studies have assessed the correlation between sources of stress and psychological morbidity in medical undergraduates. Anxiety and depression have been associated with concerns about personal endurance and ability, mastering knowledge, lack of time for other activities, feeling of anonymity, long hours, peer competition, and loss of social time.^[12],[22]

At the JNMC Sawangi (Meghe) Wardha (India), 200 students from different states of the country are admitted every year and most of them are from other states. They have diverse socioeconomic, cultural, and educational backgrounds and get exposed to a new environment. This sudden change could lead to stress of varying severity and there could be other stressors that could hamper the students' academic performance. Hence this study was undertaken with the objectives of (1) to estimate the prevalence of stress; (2) to identify the severity of depression and anxiety; and (3) to identify the sources of stress and coping strategies among students.

Materials and Methods

A cross-sectional survey was conducted among medical undergraduate students of Jawaharlal Nehru Medical College in the city of Wardha, Maharashtra, during the period of June–July 2017. A total of 169 MBBS students (2^nd year) aged 19–22 years were selected through simple random sampling. The study was conducted after obtaining approval from the ethics committee of the college. The informed consent was taken from students after explaining the nature and purpose of the study. The data were collected by self-administering questionnaires, as mentioned below:

The semi-structured pro forma that contains age, gender, religion, educational qualification, socioeconomic status, addiction status, attendance in classes, physical problems, and satisfaction with studies
Depression, anxiety and stress scale (DASS-21):^[23] It is a 21 item self-report questionnaire designed to measure the severity of core symptoms of depression, anxiety, and stress. Each item is scored from 0 to 3. It is a short-form version of the DASS (the long-form has 42 items). DASS-21 is reported to have a very good Cronbach's alpha value for depression and anxiety (0.84 and 0.74, respectively). The cut-off scores have been developed for defining mild/moderate/severe/extremely severe scores for each DASS scale
Coping inventory for stressful situations21:^[24] It is assumed to assess coping by three basic coping strategies such as avoidance, emotion oriented, and task oriented. It contains 21 items with each subscale consists of 7 items measured on 5-point Likert-scale. Higher score of each factor indicates the more frequent use and greater effectiveness of that specific coping strategy. It has also reported high internal consistencies for all the three subscales and also provide as a good factor structure
Sources of academic stress among students:^[25],[26] The questionnaire consisted of 30 items and potential stressors were divided into four categories such as relationship factors (6 items), personal factors (9 items), academic factors (9 items) and environmental factors (6 items). It was measured on five-point Likert scale ranging from 1 = no stress to 5 = highly stressful. The higher score indicates more specific stressor.

Data were analyzed using SPSS version 24.0 (SPSS Inc., Chicago, Ill., USA). The analysis was performed by descriptive and inferential statistics using the Chi-square test and t-test. Value of P < 0.05 considered as significant.

Ethical clearance

The Institutional Ethics Committee of DMIMSDU has approved the Research work proposed to be carried out at Jawaharlal Nehru Medical College, Sawangi(M), Wardha. Date: 6^th Jan 2017 with Reference no DMIMS(DU)/IEC/2019/35.

Results

A total of 169 students of 2^nd MBBS participated in the present survey. There were total 66 (39.1%) males and 103 (60.9%) females with a mean age of 19.76 (±0.98) years. Majority of them were Hindu (85.2%), belonged to upper socioeconomic status (99.4%) and moderately satisfied with their studies (66.3%). Most of the students had regular attendance in class (86.4%), no physical problems (89.9%), nonsmoking status (94.4%) and 57.99% of participants reported no addiction other than smoking [Table 1].

Table 1: Sociodemographic data of medical students

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The overall prevalences (mild to very severe) of depression, anxiety, and stress among the students were found to be 60.94%, 73.37%, and 37.27%, respectively [Table 2]. In the present study, coping strategies used by the students to deal with their stressors were task oriented (22.83 ± 5.61) followed by avoidance (21.23 ± 5.23) and emotion oriented (21.02 ± 5.86) [Table 3]. The most common source of stressors faced by participants includes academic factors (22.46 ± 7.24) followed by personal (17.69 ± 5.57), environmental (12.66 ± 4.35), and relationship factors (12.27 ± 4.36) [Table 4].

Table 2: Severity of depression, anxiety, and stress among the students

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Table 3: Coping strategies of the Medical students

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Table 4: Academic stressors among the medical students

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The student's satisfaction with studies had a significant association with depression and stress, while gender had a significant association with stress only (P < 0.05). Anxiety and other sociodemographic variables were not significantly associated (P > 0.05) [Table 5]. Depression was significantly associated with emotion and task-oriented coping strategies, whereas anxiety and stress were associated with emotion oriented (P < 0.05) [Table 6].

Table 5: Association between sociodemographic variables and depression, anxiety, and stress scores

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Table 6: Association between depression, anxiety, and stress scores and coping strategies

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The all source of stressors such as relationship, personal, environmental, and academic factors were significantly associated with depression, anxiety, and stress (P < 0.05) [Table 7].

Table 7: Association between depression, anxiety, and stress scores and sources of stress

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Discussion

A total of 169 MBBS students (2^nd year) participated in the present survey with the aim of estimating the prevalence of stress, anxiety, and depression; sources of stress and their coping strategies. The psychological morbidity in our study was variable compared to previous study from developed countries. The overall prevalence of psychological morbidity among medical students was found to be 20.9% by Sreeramareddy et al.^[9] A study from the Agha Khan University of Pakistan reported more than 90% of students felt stressed during their course.^[19] Indian study reported 73% of the students' perceived stress during their medical school.^[6] Studies from Australia, Singapore, and the United Kingdom have reported different rates of psychological morbidity among medical students.^{[27],[28],[29]} In the present survey, satisfaction with academic performance had a significant association with depression and stress, while age is associated with stress only.

In the present study, academic and personal factors as compared to environmental and relationship factors were found to be important stressors for medical students. Barikani identified economic and accommodation-related factors as probable stressors among medical students, while Vivek found environmental and social factors as important stressors in his study.^[30],[31] Researchers such as Al-Dabal et al., Abu-Ghazaleh et al., and Behere et al., have studied the importance of various academic factors in the development of stress.^{[32],[33],[34]} Hence, our finding is in accordance with that of the above researchers. All sources of stressors were significantly different with respect to depression, anxiety, and stress. Academic factors were found to have comparatively more mean score on all DASS scores as compared to other source of stressors.

Coping strategies refer to the specific efforts, both psychological and behavioral that people employ to master, reduce tolerate or minimize stressful events.^[35] Avoidance-oriented coping strategies describes activities, and cognitive changes aims at avoiding the stressful situation while task-oriented coping is described as purposeful task effort aimed at solving the problem or attempt to alter the situation. Emotion-oriented coping describes turning to religion, positive reinterpretation, acceptance and seeking of emotional support.^[36],[37] In the present survey, most common coping strategies used by students was task oriented followed by avoidance and emotion, which is similar to the findings of a study conducted by Wan Salwina et al. and Salam A et al.^[36],[38] Further depression was significantly different with emotion and task-oriented coping strategies, whereas anxiety and stress were significantly associated with emotion-oriented in the current study. The difference observed in the findings of current and previous studies could be due to differences in methodological evaluation and study population.

There are certain limitations of this study. The findings cannot be generalized since this study was conducted in a single medical college. The self-administered scales used, and hence the results could be biased. Stress at different periods was not considered in this study. Compounding factors such as the participants' personality or current emotional state may be present. This was a cross-sectional study, and small sample size was used.

Conclusion

The prevalences of depression, anxiety, and stress have been found to be variable in the current study as compared to previous literature. The main source of stress found to be academic factors with task-oriented strategy is the main coping mechanism to deal with their stressors by the students. Hence need for specific and targeted to decrease substantially the burden of students. Teaching techniques and the college environment should be adapted to the need of the students. Therefore, the promotion of healthy dietary and lifestyle habits should be encouraged.^{[39],[40],[41],[42],[43],[44],[45],[46]}

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