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Discussion

Figure 2: Forest plot of studies on anxiety or depression included in the


review. Studies identified as author, year
Figure 3: Forest plot of studies on stress included in the review. Studies
identified as author, year

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Table 2: Studies evaluating stress and mental distress among students
Author, year Place of conduct Sample size, method Assessment method Prevalence
rate (%)
Abraham et al., 2009[83] Manipal, Karnataka 115, convenience General Health Questionnaire 37.4

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Baste and Gadkari, 2014[63] Mumbai, Maharashtra 90, random sampling Self-administered questionnaire
54.4
Behere et al., 2011[84] Wardha, Maharashtra 100, random sampling Stress Measurement Scale 5.0
Brahmbhatt et al., 2013[85] Mangalore, Karnataka 200, convenience Perceived Stress Scale 42.5
Chatterjee et al., 2012[86] Kolkata, West Bengal 414, random sampling SRQ 14.5
Das et al., 2013[87] Kolkata, West Bengal 493, convenience PGWB scale 34.1
Deepali et al., 2015[88] Tumkur, Karnataka 100, convenience Perceived Stress Scale 62.0
Gupta et al., 2015[89] Kolkata, West Bengal 81, convenience MSSQ-40 91.4
Iqbal et al., 2015[67] Bhubaneshwar, Odisha 353, convenience Depression Anxiety Stress Scale
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13.3
Khaliq et al., 2010[90] Delhi 117, convenience Professional Life Stress proforma 59.8
Kittu and Patil, 2013[91] Puducherry 235, convenience Self-administered instrument 71.1
Konjengbam et al., 2015[92] Imphal, Manipur 299, convenience General Health Questionnaire 28.4
Madhyastha et al., 2014[93] Manipal, Karnataka 94, convenience Professional Students Stress
Survey
56.4
Mahawar et al., 2011[94] Indore, Madhya Pradesh 60, convenience General Health Questionnaire 86.7
Manjunath and Kulkarni, 2013[69] Mysore, Karnataka 211, convenience General Health Questionnaire
25.1
Mannapur et al., 2010[95] Bagalkot, Karnataka 251, convenience Presumptive Stressful Life Events
Scale
47.0
Mehta et al., 2015[96] Amritsar, Punjab 339, stratified random sampling SRQ-20 15.0
Modi and Kumar, 2013[70] Karamsad, Gujarat 92, convenience (final year) Self-Designed Questionnaire
45.7
Nair, 2013[97] Raichur, Karnataka 245, convenience Kessler 10 Questionnaire 58.8
Nandi et al., 2012[98] Kolkata, West Bengal 215, convenience General Health Questionnaire 52.6
Reang and Bhattacharya, 2013[99] Agartala, Tripura 146, random sampling General Health
Questionnaire 94.5
Saxena et al., 2014[100] Dehradun, Uttaranchal 100, convenience Self-Rated Questionnaire 100.0
Sharma et al., 2011[101] Indore, Madhya Pradesh 68, convenience Zung Scale for Stress 67.6
Sivan and Rangasubhe, 2013[102] Kerala 96, convenience (first year) MSSQ Cohen’s Perceived
Stress Scale General Health
Questionnaire

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93.8
69.8
65.6
Solanky et al., 2012[103] Surat, Gujarat 160, convenience Self-Rated Questionnaire 96.8
Srinivasan et al., 2006[104] Bengaluru, Karnataka 36, convenience Self-Rated Questionnaire 25.0
Supe, 1998[105] Mumbai, Maharashtra 238, random sampling Self-Rated Questionnaire 74.8
Waghachavare et al., 2013[106] Sangli, Maharashtra 406, convenience Self-Rated Questionnaire 25.1
PGWB: Psychological General Well-Being, SRQ: Self-Reporting Questionnaire, MSSQ: Medical
Student’s Stressor Questionnaire

Table 3: Gender differences in depression, anxiety, and stress


Author, year Attribute
assessed
Assessment method Prevalence rate in males
and females (%)
OR, male:female
Bassi et al., 2014[79] Anxiety Hamilton Anxiety Scale 30.8, 63.5 0.25 (0.13-0.51)
Iqbal et al., 2015[67] Anxiety Depression Anxiety Stress Scale 42 25.5, 21.1 1.28 (0.77-2.11)
David and Hashmi, 2013[64] Depression Beck Depression Inventory 6.5, 11.0 0.57 (0.15-2.20)
Iqbal et al., 2015[67] Depression Depression Anxiety Stress Scale 42 24.8, 21.1 1.23 (0.75-2.04)
Kumar et al., 2012[68] Depression Beck Depression Inventory 70.5, 72.1 0.92 (0.60-1.43)
Manjunath and Kulkarni, 2013[69] Depression CES-D 25.5, 24.8 1.04 (0.56-1.94)
Prakash and Prabhu, 2014[71] Depression Beck Depression Inventory 62.2, 60.6 1.07 (0.71-1.61)
Sahu et al., 2013[72] Depression Beck Depression Inventory 35.2, 38.9 0.85 (0.54-1.36)
Sidana et al., 2012[74] Depression Primary Health Questionnaire-9 19.8, 23.4 0.81 (0.44-1.50)
Singh et al., 2010[75] Depression Beck Depression Inventory 42.4, 60.4 0.48 (0.31-0.76)
Verma et al., 2013[78] Depression Hamilton Depression Rating Scale 27.8, 34.8 0.72 (0.31-1.69)
Chatterjee et al., 2012[86] Stress SRQ 12.0, 20.7 0.52 (0.30-0.93)
Iqbal et al., 2015[67] Stress Depression Anxiety Stress Scale 42 34.4, 28.8 1.30 (0.82-2.05)
Mehta et al., 2015[96] Stress SRQ-20 13.0, 16.3 0.76 (0.41-1.43)
Nandi et al., 2012[98] Stress General Health Questionnaire 50.0, 60.0 0.67 (0.36-1.24)

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Sharma et al., 2011[101] Stress Zung Scale for Stress 66.7, 69.0 0.90 (0.32-2.52)
Sivan and Rangasubhe, 2013[102] Stress Medical student’s Stressor Questionnaire 94.1, 93.5 1.17 (020-
6.74)
Sivan and Rangasubhe, 2013[102] Stress Cohen’s Perceived Stress Scale 64.7, 72.6 0.59 (0.25-1.42)
Sivan and Rangasubhe, 2013[102] Stress General Health Questionnaire 55.9, 71.0 0.46 (0.19-1.07)
Supe, 1998[105] Stress Self-Rated Questionnaire 74.2, 72.7 1.08 (0.61-1.92)
CES-D: Center for Epidemiological Studies-Depression Scale, SRQ: Self-Reporting Questionnaire, OR:
Odds ratio

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This systematic review suggests that depression affects roughly two-fifths of the medical
undergraduate students, while stress affects more than half of the students of medical courses, though
there was a marked variation in the reported rates of depression and stress across the studies. Female
students were more likely to be affected by depression and stress as compared to male students.
The reported rates of depression in the present review among Indian studies varied from 8.7% to
71.3%. Even with Beck Depression Inventory, the most commonly used instrument used for assessment
of depression in the Indian studies, the rates of depression ranged from 11.7% to 71.3%. The cutoff
chosen for an individual to be classified as depressed would also make a difference to the rates of
depression, though typically a cutoff of 10 and above is used for Beck Depression Inventory. Studies
from other parts of the world have also found a wide range of prevalence of depression among medical
students,[14] though a substantial proportion of medical students have been reported to be
affected.[12,14] Though a fewer number of studies addressed anxiety, it seems that about a third of the
medical students are affected by prominent anxiety symptoms.
The present review suggests that more than half of the students suffered from considerable stress.
Stress can be conceptualized in various ways,[107] and diversity exists in the manner in which stress has
been operationalized. Some amount of stress is adaptive and helps to trigger the hormonal response
needed to counter situations that are challenging emotionally and physiologically.[108] However, the aim
of this review was to find pathological stress or distress, which may have adverse outcomes in general.
The individual studies included in the review were heterogeneous in their definition of stress, and the
reported prevalence rates varied from 5.0% to even 100%.
Comparison of male and female students suggested that female students were more likely to suffer
from depression and stress, as compared to male students. This is in line with previous literature which
suggests that female medical students have higher rates of symptoms of depression, anxiety, and stress.
[14,109,110] The findings can also be contextualized with literature among the general population, which
suggest that women are more likely to suffer from depression and anxiety than men.[111] Men, on the

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other hand, are likely to suffer from substance-use disorders,[112] which, however, was not analyzed in
the present systematic review.
The high rates of depression, anxiety, and stress noted in this review are worrisome. This reflects
that the medical students are likely to experience considerable degree of psychological morbidity.
Students are likely to be primed for the medical course being a tough one at the time of preparation for
the entrance examination. Yet, many of them are not able to cope effectively with the stress that the
medical school training entails. The genesis of anxiety, depression, and stress among medical students
may be multifactorial. The inability to cope with the vast curriculum; repeated examinations; high
expectations of the parents, teachers, and patients, and time constraints for pursuing their alternate
interests may be contributory.[85,102] Depression, anxiety, and stress among medical students are often
underrecognized and undertreated. Stigma surrounding mental health issues often deters medical students
from seeking professional help.[113] Hence, medical students do not seek formalized care for
psychological distress, despite such a facility being available at close quarters. In addition, it is possible
that medical students may feel that developing resilience is a part of becoming a doctor and hence distress
would need to be endured as a part of the training.