chrismedjhealthres22119-3835622_103916(1)

7/26/2019 CHRISMEDJHealthRes22119-3835622_103916(1)

1/5

CHRISMED Journal of Health and Research /Vol 2/Issue 2/Apr-Jun 2015 119

INTRODUCTION

Stress is a state of an individual that results from theinteraction 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.[1]Individual in

a stressful situation is influenced by his or her mental

ability to carry out ongoing tasks.[2,3]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.[4]Several studies have revealed that

the incidence of stress and stress related illness such asanxiety and depression among the medical profession

are increasing day by day. Educational process exerts an

inadvertent negative effect on students mental health

with a high frequency of depression, anxiety and stress

among medical students.[5-8]

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.[6]Gender, lack of family support, are also one

of the risk factors.[9]Students exposed to work overloadin a competitive environment with constant pressure of

assessment brings various changes in their daily habits

such as lack of sleep, irregular diet, substance abuse.[10]

There are very few studies in this context in India and

very few in Maharashtra. Keeping all these factors

A study of stress, anxiety, and depression

among postgraduate medical students

Anjali N. Shete, K. D. Garkal1Department of Physiology, Government Medical College, Aurangabad, 1Registrar,Maharashtra University of Health Sciences,

Nashik, Maharashtra, India

ORIGINAL ARTICLE

A B S T R A C T

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

Access this article online

Quick Response Code:

Website:

www.cjhr.org

DOI:

10.4103/2348-3334.153255

Corresponding Author:Dr. Anjali N. Shete, Department of Physiology, Government Medical College, Aurangabad,

Maharashtra, India. E-mail: [email protected]

[Downloaded free from http://www.cjhr.org on Tuesday, May 19, 2015, IP: 180.252.17.150]


2/5

Shete and Garkal: A study of stress, anxiety and depression among postgraduate medical students

120 CHRISMED Journal of Health and Research /Vol 2/Issue 2/Apr-Jun 2015

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[11]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 [12] 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 ofperceived 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.[13]

Stascal analysis

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 moderateand 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 [Tables 2-4]. The depression score in

males was 7.17 7.70 and in females was 5.66 5.08.

The depression score in age group 2328 years

was 6.82 6.50 and in group of 2934 years was

Table 1: DASS severity levels

Grades Depression Anxiety Stress

Normal 0-9 0-7 0-14

Mild 10-13 8-9 15-18

Moderate 14-20 10-14 19-25

Severe 21-27 15-19 26-33

Extreme severe 28+ 20+ 34+

DASS: Depression, anxiety and stress scale



3/5



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

2328 years it was 10.53 3.97 and for age 2932 years

it was 10.09 3.90. For preclinical departments itwas 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 2328 years was 16.28 4.31

and for age group 2932 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 1st year of postgraduation and similar socio

economic status. These variables, therefore, were notcompared.

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.[14]Studies of medical students

from Saudi Arabia, Malaysia, Thailand identified a high

frequency of stress.[15-17]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.[1]

showed a higher prevalence of stress among female

students that were not statistically significant. Similar

findings were shown by Amar etal.[17] and Baldassin

et al.[9]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 etal.[18]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,

Table 2: Overall DASS score (n=50)

Normal Mild Moderate Severe Extreme severe MeanSD

Depression 40 06 - 03 01 6.266.00

Anxiety 10 18 16 03 03 10.343.91

Stress 24 15 10 01 - 15.303.93

DASS: Depression, anxiety and stress scale, SD: Standard deviation

Table 3: Depression scoreNormal Mild Moderate Severe Extreme severe MeanSD

Male (n=17) 13 02 - 01 01 7.177.70

Female (n=33) 27 04 - 02 - 5.665.08NS, P=0.0001

23-28 years (n=28) 21 04 - 02 01 6.826.5

29-34 years (n=22) 19 02 - 01 - 5.365.18NS, P=0.0001

Preclinical (n=25) 24 01 - - - 2.803.09

Clinical (n=25) 16 05 01 02 01 9.566.46 P=0.0001*

*Significant. n: Number of cases, NS: Not significant, SD: Standard deviation

Table 4: Anxiety score


Male (n=17) 03 07 06 - 01 9.763.63

Female (n=33) 07 11 10 03 02 10.634.06 NS, P=0.0001

23-28 years (n=28) 04 11 10 01 02 10.533.97

29-34 years (n=22) 06 07 06 02 01 10.093.90 NS, P=0.0001

Preclinical (n=25) 19 05 01 - - 8.681.49

Clinical (n=25) 07 08 07 03 - 12.004.82 P=0.0001**

**Highly significant. n: Number of cases, NS: Not significant, SD: Standard deviation



4/5


122 CHRISMED Journal of Health and Research /Vol 2/Issue 2/Apr-Jun 2015

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.

Students distress influences the professional

development and affects the academic performances.

Distressed students show decay in humanatarian

attitudes[19]and decline in empathy.[20]Medical studentsare 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.[21]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 excessiveit 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.[22]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.[1]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 responsemade 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

1. Salam A, Yousuf R, Bakar SM, Haque M. A systematic review of

literatures. Int Med J 2013;20:649-55.

2. Aris SM, Marium AD. Differences in depression, anxiety and stress

between low and high achieving students; J Sustain Sci Manage

2011;6:169-78.

3. 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.

4. 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.

5. Stewart SM,Betson C,Marshall I,Wong CM,Lee PW,Lam TH. Stress

and vulnerability in medical students. Med Edu 1995;38:479-81.6. 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.

7. Saipanish R. Stress among medical students in a Thai medical school.

Med Teach 2003;25:502-6.

8. Singh G, Hankins M, Weinman JA. Does medical school cause health

anxiety and worry in medical students? Med Educ 2004;38:479-81.

9. 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.

Table 5: Stress score


Male (n=17) 10 05 02 - - 14.053.09

Female (n=33) 14 10 08 01 - 16.244.27 NS, P=0.0001

23-28 years (n=28) 11 09 07 01 - 16.284.31

29-34 years (n=22) 13 06 03 - - 13.862.94 NS, P=0.0001

Preclinical (n=25) 21 03 01 - - 12.882.33

Clinical (n=25) 03 12 09 01 - 18.123.63 P=0.0001**

**Highly significant. n: Number of cases, NS: Not significant, SD: Standard deviation



5/5



10. Saharaian A, Javadpour A. Sleep disruption and its correlation to

pscychological distress among medical students. Shiraz E Med J

2010;11:12-7.

11. Lovibond LH, Lovibond PF. Manual for the Depression, Anxiety, Stress

Scales. 2nded. Sydney: Psychology Foundation of Australia; 1995.

12. Clark LA, Watson D. Tripartite model of anxiety and depression:

Psychometric evidence and taxonomic implications. J Abnorm

Psychol 1991;100:316-36.

13. Psychology Foundation of Australia: Depression, Anxiety, Stress

Scales. Available from: http://www.psy.unsw.edu.au/group/

dass//. [Last accessed on 2011 Apr 15].

14. Wolf TM, Kissling GE. Changes in life-style characteristics, health, and

mood of freshman medical students. J Med Educ 1984;59:806-14.

15. 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.

16. 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.

Cite this article as: Shete AN, Garkal KD. A study of stress, anxiety, and

depression among postgraduate medical students. CHRISMED J Health Res

2015;2:119-23.

Source of Support:Nil. Conflict of Interest:No.

17. Amr M, Hady El Gilany A, El-Hawary A. Does gender predict medical

students stress in mansoura, egypt? Med Educ Online 2008;13:12.

18. 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.

19. Griffith CH, Wilson JF. The loss of idealism throughout internship.

Eval Health Prof 2003;26:415-26.

20. 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.

21. 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.

22. Wong JG. Doctors and stress, the Hongkong medical Diary. Med

Bull 2008;13:4-7.


chrismedjhealthres22119-3835622_103916(1)

Documents