Accepted Manuscript

Title: Psychological Distress among College Students of

Coastal District of Karnataka: A community-based
cross-sectional survey

Authors: Shinivasa Bhat U, Amaresha Anekal, Prabhath

Kodancha, Soyuz John, Shishir Kumar, Agneita Aiman,
Praveen A Jain, Anish V. Cherian

PII: S1876-2018(18)30219-3
DOI: https://doi.org/10.1016/j.ajp.2018.10.006
Reference: AJP 1542

To appear in:

Received date: 7-3-2018

Revised date: 16-7-2018
Accepted date: 1-10-2018

Please cite this article as: Bhat U S, Anekal A, Kodancha P, John S, Kumar S, Aiman A,
Jain PA, Cherian AV, Psychological Distress among College Students of Coastal District
of Karnataka: A community-based cross-sectional survey, Asian Journal of Psychiatry
(2018), https://doi.org/10.1016/j.ajp.2018.10.006

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Title: Psychological Distress among College Students of Coastal District of Karnataka: A

community-based cross-sectional survey.

Dr. Shinivasa Bhat U1., Amaresha Anekal2, Prabhath Kodancha1, Soyuz John3, Shishir Kumar1, Agneita
Aiman1, Praveen A Jain3, Anish V. Cherian4

PT
RI
1
K. S. Hedge Medical Academy, Mangaluru, India

SC
2
Christ University, Bengaluru, India
3
Kasturba Medical College, Manipal, India

U
4
. National Institute of Mental Health and Neuro Scieinces, Bengaluru (corresponding author)

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A
Highlights
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 This survey found the high prevalence of psychological distress and suicidal ideation
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among college students.

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 Non-medical students had higher psychological distress in comparison to health and

allied sciences.
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 The students who were residing with their families and younger age had higher
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psychological distress.
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Abstract

Background:
Common Mental Disorders (CMDs) are frequent among adolescents and early adults. National

Mental Health Survey of India 2015-2016 shows alarming results, especially for depression. This

study explored the prevalence of psychological distress among college students. Additionally, the

relationship between gender, living arrangement with psychological distress in various educational

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streams were explored.

Materials and Methods:

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Through a cross-sectional community-based survey a total of 4839 college going students of

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various educational streams in Mangalore, Karnataka were assessed for psychological distress with

Self-Reporting Questionnaire (SRQ-20).

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Results:

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Participants had median age of 19 (range=9) years and the majority (59.5%) were females. The
A
median SRQ score was 4 (range 20) and about 28.5% of students were found to be psychologically
M

stressed. The suicidal ideation was reported by 13.6% of the students. Engineering and

Arts/science/commerce students had significantly higher psychological distress scores as

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compared to health and allied sciences (k=47.7; p<0.001) and those who were staying with families
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(U= 2687648.5; p=0.004) reported higher levels of psychological distress in comparison to those
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who were staying away from their families.

Conclusion:
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Prevalence of psychological distress was high among students, especially non-medical students,

students who were staying with their families, and those who were younger in age. A significant
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proportion of students had suicidal ideation, which needs early mental health interventions at the

college level.

Keywords: Psychological distress, College students, Educational streams, Suicidal ideation

1. Introduction:

Adolescent period is recognized as the most critical part of a person’s life because of major

development in physical and psychological faculties appears in this period (Christie and Viner,

2005). Literature has shown that most of the common mental health disorders would have their

PT
onset during this period (Kessler et al., 2007).

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College life considered to be stressful and may trigger psychological issues during adolescence or

early adulthood in a vulnerable individual with history of adverse childhood experience of varying

SC
degrees(Cicchetti and Toth, 2005). Some of the sources of stress among college students include

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but not limited to hostel stay, high parental expectations, academic overburden, poor time

N
management, maladaptive coping skills, and lack of recreational facilities (Al-Dabal et al., 2010;
A
Harikiran et al., 2012; Kumar et al., 2009; Shah et al., 2010; Sreeramareddy et al., 2007).
M

Common mental health disorders are alarmingly increasing among college students in recent times,

which have a significant impact on their later stages of lives (Bruffaerts et al., 2018). Some of the
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most common mental disorders among college students are depression and anxiety spectrum
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disorders (Jaisoorya et al., 2015; Sathyanarayana Rao et al., 2014). Results of western surveys
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reveals that suicidal behaviour among students is alarming (Garlow et al., 2008; Kisch et al., 2005).

This scenario is not different in India since the numbers are increasing each year (Yogini et al.,
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2012). The National Mental Health Survey of India (2015-2016) confirms that the prevalence of

the common mental disorder is high among young adults (Murthy, 2017).
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There are several studies on college students that have found a high prevalence of psychological

distress (Bernhardsdottir and Vilhjalmsson, 2013; Delara and Woodgate, 2015; Jaisoorya et al.,

2017; Stallman, 2010). Many studies have highlighted that medical or allied health science streams
have higher levels of psychological distress, depressive, anxiety symptoms and suicidal ideations

(Abdel Wahed and Hassan, 2017; Ediz et al., 2017; Ngasa et al., 2017; Rotenstein et al., 2016).

However, there is a lack of studies exploring the differences between medical and non-medical

students and association of psychological distress with socio-demographic details. Also, there are

PT
lack of studies exploring prevalence of psychological distress among students of a coastal area of

Karnataka. Hence, this study explores the association of various educational streams, age, living

RI
arrangements and gender of students on psychological distress.

SC
2. Materials and Methods:

2.1.Study Design: This cross-sectional descriptive community survey assessed the psychological

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distress among medical and non-medical college students in a coastal area of Karnataka.
N
A
2.2.Study Setting and Participants:
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The survey was conducted at various medical, nursing, dental, pharma, arts, science, and
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commerce colleges of Mangalore, a coastal town of Karnataka. A total of 4839 college students
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participated in this study.

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2.3.Tools of data collection: A semi-structured tool was prepared to collect socio-demographic

details of participants such as age, gender, course, residence etc. To assess the psychological
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distress 20-item Self-Reporting Questionnaire (SRQ-20) was used (Beusenberg et al., 1994).
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This was used to identify probable depressive, anxiety and somatic symptoms (psychological

distress) by the participants experienced in the past one month and has been used in various

settings (Beusenberg et al., 1994). Total scores range from 0 to 20 with lower scores indicating

lesser psychological distress. The <07 score on SRQ is considered as lower psychological
 distress and ≥ 07 as higher psychological distress based on a previous studies (Tawar et al.,

2014; Tuan et al., 2004).

2.4.Data Analysis: The data were analyzed with SPSS v20. Descriptive statistical tests such as

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frequency, percentage, mean and standard deviation, median and range were used to analyze

the socio-demographic details and item analysis of SRQ. The data was not normally

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distributed. Hence, the assumption free tests such as Kruskal Wallis, Mann Whitney U, and

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Spearman correlation tests were conducted to compare and correlate the psychological distress

scores among socio—demographic groups.

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N
2.5.Ethical considerations: The study protocol and informed consents were approved by human
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ethics committee of K. S. Hegde Medical Academy, Mangalore. Students were explained about
M

the survey and written informed consents were obtained prior to their participation in the study.

Students with higher psychological distress scores were offered counselling and appropriate
D

referrals were made.

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3. Results:

3.1.Socio-demographic details:
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Median age of the participants was 19 (range=9) years. More than half of the students were

female (59.5%), belongs to non-medical stream (79.12%) and staying with their families
A

(59.35%). (Table. 1)

--------------------------------Table 1 is here-------------------------------------------------------------
3.2.Psychological Distress scores:

The median SRQ score was 4 (range 20). A total of 1377 (28.5%) students had a higher cut off

scores (≥ 7) on SRQ (Table. 1). Item wise analysis (Table. 2) showed that there was a

PT
considerable proportion of students reported psychological distress in terms of worries (41.7%),

headache (40.5%), difficulty in decision making (38.2%), tiredness (30.2%), and unhappiness

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(27.8%). More importantly, a significant proportion of students reported to have suicidal ideation

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during the past month (13.6%).

--------------------------------Table 2 is here-------------------------------------------------------------

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3.3.Psychological Distress among different groups N
A
There was a significant difference on psychological distress scores between health and allied
M

health sciences students in comparison to Engineering and Arts/Science/Commerce students

(k=47.7; p<0.001).
D
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Similarly, students who were staying with their families had a significantly higher score on
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psychological distress as compared to those who were not staying with their families (U=

2687648.5; p=0.004).
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------------------------------------Table 3 is here----------------------------------------------

The proportion of students with suicidal ideation on SRQ was higher among
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Arts/Science/Commerce students in comparison to other groups (Arts/Science/Commerce =8.6%;

Engineering=2.6%; and Health and Allied Sciences=2.3%).

--------------------------------Table 4 is here-------------------------------------------------------------
It was found that the age of the Arts/Science/Commerce students was significantly lesser as

compared with other two groups (k=922.34; p<0.001). The age was found to be negatively

correlated with SRQ scores (rho=-0.093; p<0.001) and this was confirmed on Mann Whitney U

PT
test where the younger students had higher cut off scores on SRQ (U=2209908.5; p<0.001).

---------------------------------------Table 6 is here------------------------------------------------------

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---------------------------------------Table 7 is here------------------------------------------------------

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There was no significant difference on psychological distress between the genders U=2813701.5;

p=0.88).

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4. Discussion:

N
Results showed that the students who were staying away from their families and belong to non-
A
medical branches had higher psychological disturbances. Besides this, an alarming proportion of
M

students had psychological distress and recent suicidal ideation during the past month.
D

The current study’s results show that non-medical (Engineering and Arts/Science/Commerce)
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students had significantly higher psychological distress in comparison to health and allied science

students. These findings are in tune with the previous study where they found non-medical students
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report higher depressive symptoms as compared to medical students (Honney et al., 2010). Few

reviews that studied stress among medical students (Dyrbye et al., 2006), dental students (Alzahem
CC

et al., 2011; Elani et al., 2014), and nursing students(Labrague et al., 2017) reported a high
A

prevalence of stress among these groups. However, these studies have various methodological

issues, demographic variables and biological factors that might have confounded the inference.

Though, there are several reviews discuss stress among students in general (Ibrahim et al., 2013)

there is a need for comparative studies between medical and non-medical students on
psychological distress. In a developing country like India where there is a remarkable difference

in the attitude of society towards various educational streams and future prospects of each of these

educational streams, this would probably contribute significantly in how students perceive stress

in each of these educational streams. Investigation into the relationship of stress in various

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educational streams would help in adding stream specific intervention components to the existing

interventions.

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Family support and age plays an important role in alleviating the stress among students. Literature

SC
on relationship of psychological stress with living arrangements in students have reported

inconsistent results; in a study of medical students done in Mumbai, psychological stress was

U
increasing as they progressed further in medical course and was independent of living arrangement
N
(Supe, 1998); in another study higher stress levels were reported in students who stay in hostels or
A
away from home (Waghachavare et al., 2013). In a Jordanian study it was found that students with
M

high family social support reports lower levels of stress (Hamdan-Mansour and Dawani, 2008).
D

However in our culture where parental interference and control can be remarkably stressful in an
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evolving adult with inherent rebelliousness and with our sample of students in the early twenties,

the current study finding that shows a distinct result as there were higher levels of stress among
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students who were residing with their respective families in comparison to those who were staying

away from their families such as hostels, PGs or with friends could be better understood with
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reasons such as greater support from friends (Rodriguez et al., 2003) and parental pressure and
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over involvement in academic decisions or academic performance (Deb et al., 2015; Tangade et

al., 2011). However, predictors of stress among students residing with their family need further

investigation. The current study found a negative relationship between age and the psychological

distress. On exploring further, the results showed that Arts/Science/Commerce students had higher
proportion of suicidal ideations in the past month and their age was found to be significantly lesser

in comparison to other two groups. Similar results were found in a previous Australian study where

the younger students had higher psychological distress(Stallman, 2010). However, lack of studies

on association between students age and psychological distress warrants further research.

PT
Our results showed that there was an alarming proportion (13.6%) of students had suicidal

ideations in the past month. This is in tune with previous studies (Jain et al., 2012; Menezes et al.,

RI
2012; Tyssen et al., 2001) where they have reported higher suicidal ideations among college

SC
students. The item wise analysis on SRQ reveals that participants had considerably higher

proportion on several items and considerably higher cut-off scores. This could be some of the

U
reasons. Several other predictors could be underlying depressive symptoms, low social support
N
(Arria et al., 2009; Ibrahim et al., 2014; Nam et al., 2017). The National Mental Health Survey of
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India also highlights the increase in mental morbidities in the country (Murthy, 2017). This shows
M

the magnitude of the mental health issues that need to be addressed with public mental health
D

initiatives and interventions. Though this study reports some interesting findings on the prevalence
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of psychological distress among colleges students, the results should be interpreted cautiously.

Since the sample is not representative of the large community and it was drawn from the coastal
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area of Karnataka. Therefore, the results are generalizable to this population. Studies have reported

that urban residence, socio-economic status, substance abuse, history of sexual abuse, lack of peer
CC

support, self-esteem, academic demands and other factors are predictors of distress(Jaisoorya et al.,
A

2017; Saleh et al., 2017). Hence, future studies should explore the association of these factors on

psychological distress.

In conclusion, the prevalence of psychological distress among non-medical students and those

staying with their families was high. There is lack of studies with non-medical students. Thus,
implications would be to investigate predictors of psychological distress and suicidal ideation

among non-medical students. Early identification of psychological stress among students and

public mental health initiatives and intervention designed specific to educational stream to address

psychological distress among students would lead to personalized intervention for students with

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psychological vulnerabilities.

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Conflict of Interest

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None to report

Acknowledgements

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The Authors acknowledges the efforts of volunteers, Mr. Puneet Ballukaraya, Mr Dheeraj
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Devadiga and Mr. Hariprasad P. in conducting the survey. The authors thank Dr. Shalini Sharma,
Nitte University for facilitating the data collection process.
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M

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Table 1. Socio-demographic Characteristics
Socio-demographic Characteristics Mean ± SD/N (%)
Age 19.23 ±1.54
Male 1958 (40.5)
Gender
Female 2881 (59.5)
Medical Students 313 (6.5)
Engineering 1121 (23.2)

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Study Paramedical 70 (1.4)
Streams Arts/Science/Commerce 2708 (56)
Dental 397 (8.2)

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Nursing 230 (4.8)
Medical/Paramedical/Allied Health 1010 (20.87)

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Stream of Sciences
Study 3829 (79.12)
Non-Medical

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Home 2872 (59.4)
Residence Hostel 1585 (32.8)
Categories Paying Guest
With Relatives
N 324 (6.7)
58 (1.2)
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With Families 2872 (59.35)
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Residence
Outside Families 1967 (40.64)

Mean SRQ Score 4.61 ± 3.99

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SRQ < 7 3471 (71.7%)

Total SRQ score
SRQ ≥ 7 1368 (28.3%)
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Table 2. Item wise analysis of SRQ
Items of SRQ Yes No
2879
1 Do you often have headaches? 1960(40.5%)
(59.5%)
4195
2 Is your appetite poor? 644 (13.3%)
(86.7%)
1231 3608
3 Do you sleep badly?

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(25.4%) (74.6%)
1197 3642
4 Are you easily frightened?
(24.7%) (75.3%)

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1057 3782
5 Do your hands shake?
(21.8%) (78.2%)
2018 2821

SC
6 Do you feel nervous, tense or worried?
(41.7%) (58.3%)
4287
7 Is your digestion poor? 552 (11.4%)
(88.6%)

U
1286 3553
8 Do you have trouble thinking clearly?

9 Do you feel unhappy?

N (26.6%)
1345
(73.4%)
3494
A
(27.8%) (72.2%)
4198
M
10 Do you cry more than usual? 641 (13.2%)
(86.8%)
3917
11 Do you find it difficult to enjoy your daily activities? 922 (19.1%)
(80.9%)
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1859 2989
12 Do you find it difficult to make decisions?
(38.2%) (61.8%)
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3877
13 Is your daily work suffering? 962 (19.9%)
(80.1%)
3906
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14 Are you unable to play a useful part in life? 933 (19.3%)

(80.7%)
3976
15 Have you lost interest in things? 863 (17.8%)
(82.2%)
CC

4302
16 Do you feel that you are a worthless person? 537 (11.1%)
(88.9%)
4180
A

17 Has the thought of ending your life been on your mind? 659 (13.6%)
(86.4%)
1463 3376
18 Do you feel tired all the time?
(30.2%) (69.8%)
4025
19 Do you have uncomfortable feelings in your stomach? 814 (16.8%)
(83.2%)
20 Are you easily tired?
 1352 3487
(27.9%) (72.1%)

Table 3. Distribution of SRQ categories among Residence Status

Residence
Staying with Not staying with

PT
family family
SRQ Categories N (%) N (%)

RI
<Lesser than 7 2038 (42.1%) 1424 (29.4%)
7 or More than 7 835 (17.3%) 542 (11.2%)

SC
Table 4. Distribution of Suicidal ideation among study groups

U
Health and Allied
Arts/Science/Commerce Sciences Engineering
Suicidal Ideation
No
N (%)
2285 (47.2%)
N N (%)
900 (18.6%)
N (%)
995 (20.6%)
A
Yes 423 (8.7%) 110 (2.3%) 126 (2.6%)
M

Table 5. Mean Rank Difference of age between study groups

D

Median
Deanery N Mean Rank k df p
TE

(Range)
Health & Allied 1010 20(9) 3267.35 924.5 2 <0.001
Engineering 1121 20(8) 2908.69 1
EP

Arts science 2708 19(8) 1901.67

commerce
CC

Table 6. Mean Rank difference on Age among SRQ categories

A

Median Mean U df p
SRQ category N (Range) Rank
Age in <Lesser than 7 3462 19 (9) 2470.17 2209908.5 4837 <0.001
years 7 or More than 7 1377 19 (8) 2293.87
Table 7. Mean Rank Differences in Psychological Distress among Gender
Variables Median Mean Rank U p
(Range)
Gender Male (N=1958) 4 (20) 2416.53 2813701.5 P=0.88
Female (N=2881) 4 (19) 2422.36
Residence With Families 4 (20) 2467.51
(N=2873) 2687648.5 P=0.004

PT
Staying away from 3 (20) 2350.56
families (N=1966)

RI
SC
U
N
A
M
D
TE
EP
CC
A