International Journal of Current Research and Review
ISSN: 2231-2196 (Print)ISSN: 0975-5241 (Online)
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IJCRR - Vol 06 Issue 19, October, 2014

Pages: 05-09

Date of Publication: 10-Oct-2014


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ASSESSMENT OF STRESSORS IN MEDICAL STUDENTS AND ITS RELATIONSHIP WITH THE SELF-RATED DEPRESSION: A STUDY CONDUCTED IN RURAL TERTIARY HOSPITAL AND TEACHING INSTITUTE OF CENTRAL INDIA

Author: Meenakshi Khapre, Abhay Mudey, Smrutiranjan Nayak, R. C. Goyal

Category: Healthcare

Abstract:Background: Medical students are more prone to stress either due to their rigid standards and high aspiration or due to demanding education. The stress developed in undergraduates continues further in post-graduation and practice resulting in burnout. In India this area is grossly under reported. Therefore the study was carried out with the objective to find out the amount of stressors and its relation to depression. Method: A cross sectional study was carried out with complete enumeration of students present in lecture. They were educated and informed of data collection tool. i.e HESI questionnaire and MDI. Data analysis was done by descriptive and inferential statistic. Result: No difference of level of stressors was found among the students of variable academic years and sexes. 40 % were found to be mildly depressed. All of the Stressors in totality or individual except insufficient feedback and low commitment show significant correlation with MDI scores. Conclusion: Every two student out of five were found to be depressed and it is positively correlated with the stressors like work for future endurance/ capacity, non-supportive climate, faculty shortcoming, workload, financial concern

Keywords: Stressors, Self-related depression, Medical students

Full Text:

INTRODUCTION
Medical education is both long and costly. Though pursuit of higher education is expected to be stressful, medical students have more distress, anxiety and depression than any other graduates as reported by many studies (1, 2, 3). The cause of stress in medical students are mainly Long working hours, lack of peer support, competitive environment, rigid authoritative non encouraging faculty, an imbalance between professional and personal lives, lack of recreational activities, staying away from home, financial problems, residency queries, an uncertain future, emergency situations, speedy decisions, life and death issues, cultural and minority issues, mismatch between capability and expectation etc. medical students are high achiever and action oriented prior to admission. They can’t tolerate helplessness, dependency, failure. They have high aspiration but rigid standards for themselves. Therefore medical students are more prone to stress. The curriculum is vast and students are just expected to swallow without digesting or critically value it. Instead of developing the critical and intellectual relationship with medical knowledge, medical colleges just foster the students to accept the facts as said in books or lectures. Thus the road to dynamic and challenging profession is hindering overall personality development. Perceived stress is associated with increased levels of depression, alcohol and drug abuse, relationship difficulties, anxiety and suicide. (4,5) Stress is receiving increased attention because of the realization that tired, tense, anxious doc tors may not provide as high quality care as do those who do not suffer from these debilitating conditions.(6) In India medical education is provided by government and private universities. Government though provide it at nominal cost, it legally bond student for one year compulsory rural posting after completion. After completion of graduation he has to face fierce competition to establish practice, service or get post-graduation. His future is still unsecured. In India stress among medical students might be grossly underreported. To shift from distress to wellbeing we need to identify the stressors and reshape the salutary factors. Therefore to limelight the amount of stressors present in students and its relationship with the self-rated depression the above study was carried out.

OBJECTIVES
To find the extent of different stressors in medical students To assess the level of depression among the medical students To assess the relationship between the types of stressors and level of depression.

METHODOLOGY

Study Area:
The study was conducted in a Jawaharlal Nehru Medical College Study Design: A cross-sectional study design was adopted for the study.

Study Sample:
The participants of the study were the present students of medical college year 2013

Sample Selection
All the students of the college consenting to participate and were present in the class on the day of the delivering the data collection tool.

Study Tools
Higher education stress inventory (HESI)(7): 24 statements indicates presence and absence of stressful aspects like worries for future endurance /capacity, nonsupportive climate, faculty shortcoming, workload, insufficient feedback, low commitment and financial concern. Responses are rated in four point likert scale (value 1-4) does not apply at all, does not apply very well, apply fairly well and apply perfectly with reverse order for absence of stressor, so high scores are less favourable. Major depression inventory (MDI): self-rating scale to assess the depression was used. Data collection process: On a pre-decided date, after giving the general information on research, the questionnaire was administered to students present in class room. They were informed that the information retrieved would be used only for research purpose and anonymity would be maintained by giving unique ID to them. The students who were interested in knowing their scores were invited and if needed were referred to student guidance clinic in college. Analysis: only completed forms were included in final analysis report. Mean score of students for each stressor and depression was computed. The relationship between stressors and depression was analysed by Pearson moment Correlation.

RESULTS
As shown in Table 1, 48.11% were male and 51.89% were female. First year participants were 27.98 % followed by 26%, 24% and 21.6% students of second, third and fourth year respectively. Table 2 shows the mean score of HESI factor of each academic year. No significant difference was found among the academic years. 39. 9 % were found to be mildly depressed. 9.1% and 8.5% had moderate to severe depression at the time of interview as given in Table 3. Total HESI score and MDI score were strongly correlated as depicted in Table 4. Also strong correlation of MDI was seen with work for future endurance/ capacity and faculty shortcoming. Non supportive climate and workload were moderately correlated with MDI score. All of the factors in totality or individual except insufficient feedback and low commitment show significant correlation with MDI scores.

DISCUSSION
Stress in a medical school is global phenomenon. The tool used here has seven factors of which WFEC and Low commitment reflects the individual trait rather than effect of education and others like Non supportive climate, faculty shortcoming (academic), workload, insufficient feedback and financial concern reflects the environmental condition. In present study , the mean score for each stressors mentioned in questionnaire was approximately above 55% of maximum score, which depicts that this stressors are present at moderate to high level among the students. In many medical schools, the environment itself is an all prevailing pressure situation, providing an authoritarian and rigid system, one that encourages competition rather than cooperation between learners(8).

This creates the anonymity and non-supportive climate for learning. As medical students enter the clinical years, their concerns change as they find themselves unable to apply what they knew well enough for the examinations and insecurity for jobs creates worries for future. In India as per MCI teacher student ratio is 15: 1, which makes it difficult for teacher to give in dividend attention to each one of them. Many students struggle with questions about their ability to endure the demands of education. The feedback on skills and performance is crucial part in medical education to prepare the competent physician and teacher and create the interest in students but the higher score in low feedback is rather disturbing. More emphasis is given on passive learning rather than active self-directed learning. The curriculum with overload of information, and the environment presenting multiple hurdles ‘rather than opportunities for assessing progress’ are important sources of academic stress. It is not just the undergraduate study period which brings stress but it may continue during the internship, postgraduate study period, and later into physician’s practical life (9). The study done by Sidhu had shown that Indian students had increases stress score than Chinese and malaysisan in all the aspect academics, social, financial etc.(10) Present study does not show any significant difference among the level of stressors in between the academic years and sexes. These stresses are constantly present in all the academic years and equal in both sexes. Being a cross sectional study the changes through the transition from first year to final cannot be depicted. There are contradictory findings as some studies (1, 11, 12) showed increase in level of stress from progressing academic years while other showed decrease (13). The finding of No difference of level of stressors among the sexes is in line with other studies (11, 14). While some studies indicates female medical students perceive more stress (15) also as per available records the suicidal and depression rates in female students are more than males. The present study was conducted in private institution with well to do family may be the reason for study findings. 37.5 % scored more than cut off point of which 8.5 % that scored very high were in need of psychological counselling. Depression is quite common in medical students and range from 6 % (16) to 25 % (17) using different measures and definitions. Considering the Cohens guidelines for behavioral studies(18) all the stressors except insufficient feedback and low commitment showed the significant positive correlation with MDI score. Work for future capacity and faculty shortcoming was strongly correlated while Non supportive climate and workload were moderately correlated with MDI score. Strong positive correlation was found between total HESI score and MDI score. This shows that level of stress increases the chances of depression. Ability of medical students to deal with stress depends on multiple factors, including individual vulnerability, and psychological and social resources as well as stressors (19). The degree of distress depends on the balance between the stressors and the resources. It is necessary to increase the personnel resources by educating them for stress and time management techniques and coping skills in order to diminish the perceived distress. The stressor therefore has to be identified need to be address by policy maker, teachers, psychologist and family members.

CONCLUSION
Every two student out of five were found to be depressed and it is found to be positively correlated with the stressors like work for future endurance/ capacity, non-supportive climate, faculty shortcoming, workload, financial concern. Thus this stressors need to be address to reduce the distress in medical graduate.

RECOMMENDATION
It is time to make Medical education interesting by innovative active learning methods, restore enthusiasm in the students and to project a more realistic, humane image of the profession. The student guidance clinic should be functional by regular screening and assisting the student with psychological problems. The orientation programmes and counselling services should be started from the entry level. The students must be made aware of the stress and its self-management. It is imperative that future Physicians are healthy themselves before they Treat others.

ACKNOWLEDGEMENT
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.

References:

1. Helmers , K.F, Danoff , D, Steinert ,Y Leyton, M and Young, S.N (1997) Stress and depressed mood in medical students, law students, and graduate students at Mc Gill University Academic medicine , 72, 708-14.

2. Rautio, A, Sunnari , V, Nuutinen ,M and Laitala , M (2005) Mistreatment of university students most common during medical studies BMC Medical education[online], 5(36)available from : http//:www.biomedcentral.com/1472- 6920/5/36

3. Frank, E. Carrera, J.S, Stratton, T, Buckle, J and Nora. L.M (2006) experience of belittlement and harassment and their correlates among medical students in the United states: longitudinal survey BMJ, 333, 682.

4. Shapiro S, Shapiro D, Schwartz G. Stress management in medical education: a review of the literature. Acad Med2000;75:748–59.

5. Stecker T. Well-being in an academic environment. Med Educ2004;38:465–78

6. Firth-Cozens J. Doctors, their well-being, and their stress. BMJ2003;326:670–1

7. Marie Dahlin, Future Doctor,Mental distress during medical education: cross sectional and longitudinal studies, publish by Karolinska University press, Stockholm, Sweden 2007.

8. Styles WM. Stress in undergraduate medical education: ‘the mask of relaxed brilliance’. Br J Gen Pract 1993;43:46-7.

9. Tyssen R, Vaglum P, Gronvold NT, Ekeberg O. The relative importance of individual and organizational factors for the prevention of job stress during internship: a nationwide and prospective study. Med Teach 2005;27:726-31

10. Jagmohni Kaur Sidhu, Effect of Stress on Medical Students, IeJSME 2007: 1 (1): 52-53

11. Niemi PM, Vainiomaki PT. Medical students’ distress—quality, continuity and gender differences during a sixyear medical programme. Med Teach2006;28:136-41.

12. Dyrbye L, Thomas MR, Shanafelt TD. Medical student distress: causes, consequences, and proposed solutions. Mayo Clin Proc2005;80:1613-22.

13. Guthire E, Black D, Bagalkote H, Shaw C, Campbell M, Creed F. Psychological stress burnout in medical students: a five-year prospective longitudinal study. J R Soc Med1998;91:237-43

14. Kilkkinen A, Kao-Philpot A, O’Neil A, Philpot B, Reddy P, Bunker S et al. Prevalence of psychological distress, anxiety and depression in rural communities in Australia. Aust J Rural Health 2007;15:114-9.

15. Amr, M., EL Gilany, A.H. and EL-Hawary, A. (2008) Does gender predict medical students stress in Mansura, Egypt Medical Education Online, 13:12, available at http/www. med.edonline.org

16. Zoccolillo , M, Murphy , G. E and Wetzel, R.D (1986) Depresseion among medical students Journal of affective disorder,11,91-6

17. Givens , J.L and Tjia, J(2002) Depressed medical students use of mental health services and barriers to use, Academic medicine .77(9): 918-21.

18. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Erlbu.

19. Vitaliano P, Maiuro R, Russ J, Mitchell E. Medical student distress: a longitudinal study.J Nerv Ment Dis 1989;177(2):70–6.


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Awards, Research and Publication incentive Schemes by IJCRR

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One article from every issue is selected for the ‘Best Article Award’. Authors of selected ‘Best Article’ are rewarded with a certificate. IJCRR Editorial Board members select one ‘Best Article’ from the published issue based on originality, novelty, social usefulness of the work. The corresponding author of selected ‘Best Article Award’ is communicated and information of award is displayed on IJCRR’s website. Drop a mail to editor@ijcrr.com for more details.

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Best Article Award

A Study by Juna Byun et al. entitled "Study on Difference in Coronavirus-19 Related Anxiety between Face-to-face and Non-face-to-face Classes among University Students in South Korea" is awarded Best Article for Vol 12 issue 16
A Study by Sudha Ramachandra & Vinay Chavan entitled "Enhanced-Hybrid-Age Layered Population Structure (E-Hybrid-ALPS): A Genetic Algorithm with Adaptive Crossover for Molecular Docking Studies of Drug Discovery Process" is awarded Best article for Vol 12 issue 15
A Study by Varsha M. Shindhe et al. entitled "A Study on Effect of Smokeless Tobacco on Pulmonary Function Tests in Class IV Workers of USM-KLE (Universiti Sains Malaysia-Karnataka Lingayat Education Society) International Medical Programme, Belagavi" is awarded Best article of Vol 12 issue 14, July 2020
A study by Amruta Choudhary et al. entitled "Family Planning Knowledge, Attitude and Practice Among Women of Reproductive Age from Rural Area of Central India" is awarded Best Article for special issue "Modern Therapeutics Applications"
A study by Raunak Das entitled "Study of Cardiovascular Dysfunctions in Interstitial Lung Diseas epatients by Correlating the Levels of Serum NT PRO BNP and Microalbuminuria (Biomarkers of Cardiovascular Dysfunction) with Echocardiographic, Bronchoscopic and HighResolution Computed Tomography Findings of These ILD Patients" is awarded Best Article of Vol 12 issue 13 
A Study by Kannamani Ramasamy et al. entitled "COVID-19 Situation at Chennai City – Forecasting for the Better Pandemic Management" is awarded best article for  Vol 12 issue 12
A Study by Muhammet Lutfi SELCUK and Fatma COLAKOGLU entitled "Distinction of Gray and White Matter for Some Histological Staining Methods in New Zealand Rabbit's Brain" is awarded best article for  Vol 12 issue 11
A Study by Anamul Haq et al. entitled "Etiology of Abnormal Uterine Bleeding in Adolescents – Emphasis Upon Polycystic Ovarian Syndrome" is awarded best article for  Vol 12 issue 10
A Study by Arpita M. et al entitled "Estimation of Reference Interval of Serum Progesterone During Three Trimesters of Normal Pregnancy in a Tertiary Care Hospital of Kolkata" is awarded best article for  Vol 12 issue 09
A Study by Ilona Gracie De Souza & Pavan Kumar G. entitled "Effect of Releasing Myofascial Chain in Patients with Patellofemoral Pain Syndrome - A Randomized Clinical Trial" is awarded best article for  Vol 12 issue 08
A Study by Virendra Atam et. al. entitled "Clinical Profile and Short - Term Mortality Predictors in Acute Stroke with Emphasis on Stress Hyperglycemia and THRIVE Score : An Observational Study" is awarded best article for  Vol 12 issue 07
A Study by K. Krupashree et. al. entitled "Protective Effects of Picrorhizakurroa Against Fumonisin B1 Induced Hepatotoxicity in Mice" is awarded best article for issue Vol 10 issue 20
A study by Mithun K.P. et al "Larvicidal Activity of Crude Solanum Nigrum Leaf and Berries Extract Against Dengue Vector-Aedesaegypti" is awarded Best Article for Vol 10 issue 14 of IJCRR
A study by Asha Menon "Women in Child Care and Early Education: Truly Nontraditional Work" is awarded Best Article for Vol 10 issue 13
A study by Deep J. M. "Prevalence of Molar-Incisor Hypomineralization in 7-13 Years Old Children of Biratnagar, Nepal: A Cross Sectional Study" is awarded Best Article for Vol 10 issue 11 of IJCRR
A review by Chitra et al to analyse relation between Obesity and Type 2 diabetes is awarded 'Best Article' for Vol 10 issue 10 by IJCRR. 
A study by Karanpreet et al "Pregnancy Induced Hypertension: A Study on Its Multisystem Involvement" is given Best Paper Award for Vol 10 issue 09
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List of Awardees

Awardees of COVID-19 Research

Woman Researcher Award

A Study by Neha Garg et al. entitled "Optimization of the Response to nCOVID-19 Pandemic in Pregnant Women – An Urgent Appeal in Indian Scenario" published in Vol 12 issue 09

A Study by Sana Parveen and Shraddha Jain entitled "Pathophysiologic Enigma of COVID-19 Pandemic with Clinical Correlates" published in Vol 12 issue 13

A Study by Rashmi Jain et al. entitled "Current Consensus Review Article on Drugs and Biologics against nCOVID-19 – A Systematic Review" published in Vol 12 issue 09

Emerging Researcher Award

A Study by Madhan Jeyaraman et al. entitled "Vitamin-D: An Immune Shield Against nCOVID-19" published in Vol 12 issue 09

Study by Dheeraj Kumar Chopra et al. entitled "Lipid-Based Solid Dispersions of Azilsartan Medoxomil with Improved Oral Bioavailability: In Vitro and In Vivo Evaluation" published in Vol 12 issue 19


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