IJCRR

IJCRR - 13(9), May, 2021

Pages: 52-58

Date of Publication: 07-May-2021

Prevalence of Psychiatric Morbidity in Undergraduate Medical Students in a Rural Medical College of Central India using Global Mental Health Assessment Tool - Primary Care (GMHAT-PC)

Author: Prakash B Behere, Anweshak Das, Aniruddh P Behere, Amit B Nagdive, Richa Yadav, Rouchelle Fernandes

Category: Healthcare

Abstract:Background: Many studies report that medical education is one of the toughest courses and that life in a medical college can be quite engaging, demanding and straining to lead to stress both physically and emotionally. It is also observed that many medical students even if having mental health issues would hesitate to contact help providers, especially psychiatrists. It may be due to stigma, negative criticism and discrimination attached to mental illness or due to negative opinions regarding mental illness. Medical students hesitate to seek help from their college and instead prefer to go to another psychiatrist in a different town. It has been time and again stated that early detection and treatment improves the prognosis and reduces lifelong negative consequences.
Objective: To find the prevalence of psychiatric morbidity in undergraduate students of a private medical college in Central India.
Methods: Students were assessed using GMHAT-PC, which is a computer-based diagnostic tool designed to be used in the primary health care setting.
Results: Female participants were significantly more than male participants. Female participants also had a significantly higher prevalence of mental illness compared to their male counterparts.
Conclusion: Medical schools need to give priority to student welfare and not merely focus on student distress. Academic stress has a significant correlation with the prevalence of mental illness. Apart from academic studies, students must also be given the knowledge to improve their coping skills, manage their anger, skills on emotional regulation, impart them skills on conflict resolution and also give them some knowledge to improve their resiliency. These can be possible through Life Skill education and also Social Emotional Training Program.

Keywords: GMHAT-PC, Help-seeking behaviour, High prevalence of anxiety

Full Text:

INTRODUCTION

Globally medical colleges or medical schools strive to usher in an environment where all their students (both undergraduates and post-graduates) become both skilful enough and knowledgeable enough to better serve the society in their profession as a doctor. These problems hamper academic development, learning of clinical skills and professional abilities.¹ Many studies report that medical education is one of the toughest courses and that life in a medical college can be quite engaging, demanding and straining to lead to stress both physically and emotionally.²

Life in a Medical college starts around the age of 18.  This is the transition phase of late adolescence and early adulthood. Most of us start taking adult roles taking major social roles and responsibilities. Students learn for the first time in their lives to live on their own, maintaining a balance of demands of course work and social life, adjusting to roommates, hostel life, making new relations, cooking food at times, maintaining finances which are challenging and stressful. Although some students can weather this stormy and stressful stage, many students buckle under this stress, cannot cope with the changes and experience emotional maladjustment and psychological problems. Seventy-five per cent of mental illnesses start before age of 24 years which is the prime age of medical education.³ The goals of medical education is to train physicians who are prepared to serve the fundamental purposes of medicine – with requisite knowledge, skills, attitudes, values and responsiveness, so that they may function appropriately and effectively as a basic doctor, physicians of the first contact for the community in the primary care setting both in urban as well as rural areas of our country.⁴  The Bachelor of Medicine and Bachelor of Surgery (MBBS) course in India like in other countries is very demanding and rigorous, taking a toll emotionally in many students leading to depression, anxiety and the unfortunate incidents of suicide or suicidal attempts by the students. The most commonly observed sources of stress were fear of failure,  inability to cope with the expectations of parents and peers, lack of peer support, competitive environment, long working hours, difficulty in adjusting, relationship issues, residency uncertainty, family history of mental illness are few reasons of stress.^5-7

Gender differences differ from study to study. While some studies have reported that female medical students suffer more. Symptoms suggestive of neuroticism, depression, anxiety, and somatic symptoms were more in female students; other reports have found no sex differences in stress perception.⁸ For many students the first year is found to be more stressful. Other reports have however suggested that the 2nd and 3rd year is stressful. Surprisingly, the psychological morbidity of the first year and fourth year is similar. The however stressful period during the MBBS course has differed from study to study.⁵

Studies worldwide have reported high levels of anxiety, stress and depression in medical students. A study in Saudi Arabia reported the prevalence of severe stress was 25% in medical students.⁹ In another cross-sectional study in the medical school of New Delhi, the prevalence of provisionally diagnosed depressive disorder was 21.5.¹⁰ One of the studies on undergraduate medical students in the rural area of North-West India, 43% showed psychological distress.¹¹ Another cross-sectional study of 400 medical students from Rural Medical College, Loni reported prevalence of psychiatric morbidity stood at 29.75%.¹² A study done in a private medical college in Uttar Pradesh found significant stress and anxiety and depression in medical students of the college.¹³ Another study was done on medical students in a medical college of Bangalore reported   42.38% had some form of depression, 54.96% had some form of anxiety and 45.69% had some form of stress.¹⁴ The prevalence of depression among medical students in India was found to be 71.25%.¹⁵ Anxiety and depression were found to be present in 70% according to a Pakistani study.⁷ In an Egyptian study 44% of medical students were diagnosed to have mood and anxiety symptoms.^16,17

It is also observed that many medical students even if having mental health issues would hesitate to contact help providers, especially psychiatrists. It may be due to stigma, negative criticism and discrimination attached to mental illness or due to negative opinions regarding mental illness. Medical students hesitate to seek help from their college and instead prefer to go to another psychiatrist in a different town. It has been time and again stated that early detection and treatment improves the prognosis and reduces lifelong negative consequences.^8,18 This would also contribute to the reduction of the global burden on health and social care systems caused by mental disorders.¹⁹  So it is of utmost importance that we give impetus on early identification and prevention of mental health issues. Modern technology especially computer-assisted methods can be used to augment the available human resources in the health and social well-being sector, especially in low to middle-income countries.¹⁹ GMHAT-PC screening is an easy to use screening method that can be used in the community. It can be used by other mental health professionals as it gives the diagnosis along with its differentials as per the ICD-10 criteria.

In this study, the main aim was to find out the prevalence of psychiatric morbidity in undergraduate students of Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha and whether the frequency of morbidity changes in subsequent years of education.

MATERIALS AND METHODS

The study was conducted in Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha. It was a cross-sectional study with a single evaluation was done. Subjects were selected as random sampling. A total of 650 MBBS students were selected. Electronically data was collected on the GMHAT-PC.

Institutional Ethics Committee approval was taken vide letter number DMIMS (du)/IEC/2012-2013/957. Confidentiality was ensured. They were informed that if any mental illness was detected the help will be provided.

The following were the inclusion criteria:

1. Undergraduate students from the first to fourth years were included.

2. Both sexes were included.

3. Students who were willing to give written informed consent.

Those students who did not give their consent were not interviewed and were excluded from the study. The instrument used was Global Mental Health Assessment Tool – Primary Care Version (GMHAT – PC) – Computer Software. It gives at the end, ICD-10 diagnosis and also, the differential diagnosis. A summary report consisting of symptoms along with their scores is generated and the GMHAT/PC diagnosis is given. The part on history has six sections: presenting problems, past mental health, physical health, family history, personal and social history and substance misuse. There are then sections on mental state examination, assessment of unmet needs and risk assessment. Further sections focus on diagnosis, an overall summary, relevant investigations required, a care plan and a section to gather third party information and to detail the progress on the ward. Finally, there is a checklist of items of explanation to the service-user and the caregivers.

RESULTS

A total of 390 students were enrolled in the study. Two hundred sixty students were excluded from the analysis as 140 did not provide consent to participate in the study, 63 were previously diagnosed to have a psychiatric disorder and 57 students were unavailable to interview. The remaining 390 students were assessed using GMHAT-PC.

Female students were significantly higher in number in the sample, compared to male students. There were 158 (40.5%) male students and 232 (59.5%) female students. This statistically significant difference was seen in 3^rd year M.B.B.S. students as well (27.4% vs 72.6%, p=0.001). However, there was no statistically significant difference between males and females in 1^st, 2^nd, and 4^th-year students. These findings are shown in Table 1.

Out of 390 students assessed using GMHAT-PC, 144 (36.92%) were found to have a mental illness. A total of 38 (9.7%) male students and 106 (27.2%) female students were found to have a mental illness. Among these students, the majority were from the final year (40.2%), followed by 2^nd-year students (38.6%), 1^st year students (35.9%) and 32.1% from the 3^rd year of M.B.B.S. There was no statistically significant difference between students from different phases of their education, However, a statistically significant difference was seen between male and female students, with mental illness being significantly higher in female students compared to males. These findings are depicted in Table 2.

Out of 390 students 144 (36.92%) students were diagnosed as having a mental illness. Females were significantly higher than males to have a mental illness. Among these students (n=144), anxiety disorder was the most commonly diagnosed mental illness. Forty-four (10.8%) students were found to have an anxiety disorder.  Depression was the next common mental illness which was diagnosed in a total of 39 (10%) students. Phobia which was mainly social phobia was diagnosed in 21 (5.38%) students. stress was found in 14 (3.42%) of students. Hypochondriasis was found in 5 (2.29%) students of which 4 students were female. They were mostly concerned about their weight. OCD was reported in 3 students (0.77%). The eating disorder was found in 2 (0.51%) students. Both these students were females. 3 (0.77%) students were diagnosed to have psychosis with depression of which 1 student had bipolar disorder. There was 1 (0.26%) student who had schizophrenia who was diagnosed as having psychosis. No statistically significant difference was found in illness wise distribution among boys and girls as shown in Table 3.

DISCUSSION

In the study out of 650 undergraduate medical students, 390 gave their willingness to participate in the interview (response rate was 60%). Some of the students who failed to pass the annual exams and were not in the regular batch of students were also lost. Overall, there were 158 (40.51%) male students and 232 (59.48%) female students which were statistically significant. In the 1st MBBS, there were 45 (43.46%) males and 58 (56.31%) females. In 2nd MBBS there were 45(44.55%) males and 56(55.45%) females. In the 3rd MBBS, there were 23 (27.38%) males and 61(72.62%) females and in the final MBBS, there were 45 (44.12%) males and 57 (55.45%) females. The only significance in gender-wise yearly distribution was found in the 3rd MBBS students. Males were less in the third year as most of them were not in the hostel when the interview sessions were conducted.

Out of 390 students 144 (36.92%) students were diagnosed as having a mental illness. A total of 38(9.74%) male students and 106 (27.18%) female students were diagnosed to have a mental illness. The reported prevalence of mental illness was 20.9%²⁰, 43%¹¹, 29.75%²¹, 55%²², 16%.²³ Out of 144 students diagnosed as having some mental illness, 41 (40.20%) were from final year followed by 39 (38.61%) from 2nd year, 37(35.92%) from 1st year and 27 (32.14%) from 3rd year. There was no significance found in the distribution of illness from 1st year to final year students. However, in the gender-wise distribution of mental illness, it came out to be significant with females having more mental illness than males. Other studies^9,22 reported a higher prevalence of emotional distress in females than males. In one study males showed a greater prevalence of mental illness than females.¹¹ In this study females were statistically significant than males. This may be the reason for the increased prevalence of mental illness in females than males. Also, coping strategies were found to be less in females as compared to males. Females react more to a particular situation while males distract. In a small town like Wardha recreational facilities were less for females as compared to males. These factors also contributed to the increased prevalence of mental illness in female students as compared to their male counterparts.

There was no significance found in the distribution of illness from 1st year to final year students. This was in contradiction to other studies. Most of the studies showed statistically significant variation of mental illness with years of study. ^9,10,21,24 One study found more emotional disturbances in 2^nd year and 3^rd-year students than 1^st-year students. ²⁵ Most of these studies quoted higher emotional distress in first-year students as they have to adjust to the new environment, cope up with the academic pressure and stay away from home. Final year students also showed a higher prevalence of mental illness mostly emotional distress due to academic pressure, stress of examination, highly competitive environment, uncertain future and pressure of getting into a post-graduation course. In this study first-year, students were interviewed within one or two months of their admission, when they were still new to the medical academics, without exposure to the vast courses of medicine, exam pressure, patient and clinical postings. Most of them were happy and still excited to get admitted to a medical school whereas, the final year students had high stress levels as they had to pass their final MBBS exams. They had their seminar presentations, clinics, pressure to do well in exams and a very rigorous and high competitive routine to follow. Most of them stated that even after passing their final MBBS their future was uncertain as they had to get into a post-graduate course which is very difficult in India due to limited seats for M.D/M.S.

In this study 44 (10.77%) students had anxiety which was the highest diagnosed mental illness. Depression was the next common mental illness to be diagnosed with a total of 39 (10%) students having depression. Also, stress was found in 14 (3.42%) of students. This was concerning other previous studies which reported high levels of anxiety, stress and depression in undergraduate medical students.^25-29 Although in all previous studies the prevalence rate of anxiety, depression and stress varied. In previous studies, the commonest factor responsible for stress and anxiety were academic and professional factor.^30-32 The present study also has found the same factors responsible for anxiety and stress. Study-related stress was the most common factor. The other factors were relationship problem, difficulty in adjusting to new friends or roommates, family issues. A very few quoted financial reasons as a stressor. Anxiety was mostly associated with a mild degree of panic symptoms. Depression was mostly associated with decreased concentration, easy fatigue. However, sleep disturbances, loss of appetite and feeling of hopelessness were not very common. GMHAT also gave a comorbid diagnosis of stress and anxiety in 10 students. In most of the students diagnosed with depression, GMHAT also gave anxiety and stress as the other possible diagnosis. Another finding in this study was 69 students, 23 (9.35%) male and 46 (18.70%) female had some anxiety features and these students showed some score in the anxiety domain, but the score was not enough for them to be diagnosed as having mental illness by GMHAT. Similarly, 35 students, 12(4.88%) male and 23(9.35%) female had depressive symptoms and the 31 students 9(3.66%) were male and 22(8.94%) females have symptoms of stress. These students were not diagnosed as having mental illness by GMHAT.

Phobia which was mainly social phobia was diagnosed in 21 (5.38%) students. These students mainly had fear of public speaking, speaking in front of the whole class, presenting a seminar or presenting a case. Hypochondriasis was found in 5 (2.29%) students (M: F= 1:4). They were mostly concerned about their weight. OCD was reported in 3 students (0.77%). Eating disorders were found in 2 (0.51%) students. Both these students were females. Eating disorders were found in other previous studies also.^33-35 There was 1 (0.26%) student who was diagnosed as having schizophrenia, GMHAT gave the diagnosis as psychosis. Three (0.77%) students were diagnosed to have psychosis with depression of which 1 student had bipolar disorder. This low prevalence of psychosis was concerning the earlier study. ²² 2 out of 14,600 students registered with the Leeds Student Medical Practice had a recorded diagnosis of Schizophrenia.³⁶

            Thirty-four (23.61%) students out of 144 students having mental illness had the risk of self-harm or suicidal ideation. Out of these 34 students, 28 students had a mild degree of self-harm ideation and 6 had a moderate degree of self-harm ideation. Out of 246 students who were diagnosed to have no mental illness 2 students showed a mild degree of suicidal ideation. There was no student found to be having a severe degree of suicidal ideas. Also, no one has attempted suicide till now.

An interesting finding in this study was that one student being diagnosed as having alcohol abuse. Many of the students reported having an addiction to nicotine (cigarette smoking) (it cannot be diagnosed by GMHAT). Although many students, including females, do take alcohol almost everybody denied taking alcohol. This may in fear of getting punished by the college administration even though they were earlier intimidated that confidentiality will be maintained. Many of them cited that it was difficult to get alcohol, Wardha being a dry district. The same was with illicit drug use as no student admitted having or taking any illicit drug.

It was seen out of 144 students diagnosed to having mental illness only 29 (20.13%) students are seeking help from a psychiatrist and have visited the Psychiatry OPD for treatment. In a previous study, it was seen that only 22% of students having psychological distress seek help or use health services for treatment.²⁸ In another study done in India reported 4.7% of students seeking help from a counsellor.¹⁰

CONCLUSION

Medical schools need to give priority to student welfare and not merely focus on student distress. The present study reports a high prevalence of anxiety, depression and stress in medical students which is comparable with studies done around the globe. Academic stress has a significant correlation with the prevalence of mental illness. The Year of the study did not have an impact on the prevalence of mental illness. Females showed more susceptibility towards having a mental illness. Apart from academic studies, students must also be given the knowledge to improve their coping skills, manage their anger, skills on emotional regulation, impart them skills on conflict resolution and also give them some knowledge to improve their resiliency. These can be possible through Life Skill education and also Social Emotional Training Program which should be made part of the medical education curriculum. Students in the medical fraternity are disinclined to ask for help for their mental illness. Initiatives must also be taken to improve their help-seeking behaviour.  This calls for collective responsibility in a holistic and integrated manner and a coordinated effort from their parents, teachers, and friends and most importantly the policymakers and management of the medical college they are studying.

CONFLICT OF INTEREST: None declared.

SOURCE OF FUNDING: None

ACKNOWLEDGEMENT: Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript and also acknowledge the contribution of our study participants. 

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