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The Prevalence of Stress, Depression, and Anxiety in Medical Students

Nathan Edwards, Andrew Saady-Habib, Deborah Ilufoye, Joyce Cheng, Sarah Lynch, Khoa Nguyen, and Danil Hammoudi

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Every student will tell that education starts and is accompanied with the stress, depression, and anxiety. But the journey to becoming a doctor often starts with the extreme extent of those feelings and continues along the whole career path.

While a little bit of stress can be a good thing as it motivates students to knuckle down and work hard; these responses, when exaggerated,  can drastically hinder student’s performance and negatively affects both their social, emotional and behavioral development and the feelings about themselves and the school. Learning how to cope with physiological and physical symptoms is, therefore, a matter of the uttermost importance.

Pre-test, test and post-test symptoms and signs have been studied formally since the early 1950s. SJSM students wanted to contribute to those studies, to explore the extent of the influence of stress, depression, and anxiety on students’ studies and performance and maybe to suggest the best ways to balance positive and negative effects of the “exam syndrome”. Let’s see what they found.

Abstract

This study sets out to investigate the prevalence of stress, depression, and anxiety in medical students. Researchers analyzed the St. James School of Medicine student population. Over two semesters, we measured the three factors in question utilizing the DASS diagnostic test. Our null hypothesis for this study indicates there will be no difference in stress, anxiety, and depression levels before block exams, and after block exams. Our alternative hypothesis indicates there is a possible difference in these factors before the exam and after the exam. However, with a p-value lower than .05 for each measured variable, in each block, we as a team decisively rejected the null hypothesis. The academic format of the St. James School of Medicine places their students in a situation in which they take a single block exam that weighs around 70% of their total block grade. The pressure of this exam has been found to induce significant levels of stress, depression, and anxiety. This current study is a continuation of a previous study. Our findings are almost identical to the findings from previous research; the previous studies’ results strengthen the validity of our findings. These medical students showed a significant increase in stress, depression, and anxiety in the pre exam period as compared to the post exam period.

Key words: medical students stress, depression, and anxiety measurement

Introduction

According to research from Schernhammer, many medical doctors suffer from depression leading to a subtle yet significant rate of suicide among practicing physicians (2005). Stress, depression, and anxiety, maintain an intricate relationship within the field of medicine. Even the journey to becoming a doctor can be considered emotionally taxing. To evaluate the latter point, we must explore to what extent does stress, depression, and anxiety play a role in medical students’ studies or performance.

This current study investigates these three factors in the medical student population. Although it can be argued that medical students lack the amount of responsibilities of a practicing physician. However, the field of medicine requires that only the best of the best make it as doctors; and according to the research of Treadway and Chatterjee many students stress and get anxious with regards to obtaining certain grades, to graduate and land the residency they desire (2011). Grades and academic success seem to be the main source of medical students stress, depression, and anxiety. With the utilization of the Depression Anxiety and Stress Scale (DASS) from the University of Melbourne, our research team investigated these three variables in the St. James School of Medicine students. In accomplishing this, we can objectively measure if academic performance impacts students stress, depression, or anxiety levels.

Our research was conducted in an online survey format. This allows the participant to privately indicate their level of stress at different times during the study. The results of this study can shed light on the prevalence of these factors in the medical students’ daily lives. Furthermore, we can then find ways to alleviate these mental obstructions that hinders their ability to study medicine in a safe and efficient manner.

Materials and Methods

Overview:

We utilized the DASS to measure stress, depression, and anxiety. This diagnostic test provides the researchers with a scale for each factor being measured (stress, depression, and anxiety). This scale ranged from normal, mild, moderate, severe, to extremely severe. With that being said, every variable was divided into two categories, stressed, or not stressed, depressed or not depressed, and anxious or not anxious. We placed any participant who scored in the normal range to be considered non-stressed, or non depressed or etc. Anyone who scored above normal was placed in the stressed, depressed, or anxious category. This study occurred over two semesters. This translates to over eight months in a calendar year. Each semester is divided into four blocks. Each block spans the duration of a month. We took three blocks of data from each semester and combined the data of semester 1 block 1 with data of semester 2 block 1 to represent total block 1 data. Finally, with our total block 1 data we ran a two-tailed paired t-test at significance level of .05 to determine if our results were significant. We followed this format for block 2 and 3 data of both semesters for each variable.

The research was conducted to determine if there were any correlations between the emotional states of depression, anxiety and stress before and after exams in medical school. The DASS (Depression Anxiety and Stress Scale) assesses dysphoria, hopelessness, devaluation of life, self-deprecation, lack of interest/involvement, anhedonia, and inertia; anxiety scale assesses autonomic arousal, skeletal muscle effects, situational anxiety, and subjective experience of anxious affect. The stress scale to assess the difficulty relaxing, nervous arousal, and being easily upset/agitated, irritable/over-reactive and impatient

Participants were asked to use 4-point (0-3) severity/frequency scales to rate the extent to which they have experienced each state pre- and post- exam. Scores for Depression, Anxiety and Stress are calculated by summing the scores for the relevant items.

Materials

  • Computer(s)
  • Office software – Excel
  • Internet
  • Cloud shared services – Google drive
  • Depression, Anxiety and Stress Scale (DASS) scale
  • Social media – Facebook

Procedure:

We used a Stress Questionnaire based on the depression, anxiety, and stress (DASS) scale on the Google drive and created a consent form for our participants. We used students from MD1 to MD4 who wanted to participate in our study. We notified the participants the day before and the day of the exams to do their Stress Questionnaire through email and social media (Facebook). Any participant who did not complete all of their surveys were eliminated from the study. The scale categorizes 42 questions based on the 3 scales, Depression/Anxiety/Stress with 14 questions each as follows:

Depression scale

  • self-disparaging
  • dispirited, gloomy, blue
  • convinced that life has no meaning or value
  • pessimistic about the future
  • unable to experience enjoyment or satisfaction
  • unable to become interested or involved
  • slow, lacking in initiative

Anxiety scale

  • apprehensive, panicky
  • trembly, shaky
  • aware of dryness of the mouth, breathing difficulties, pounding of the heart, sweatiness of the palms
  • worried about performance and possible loss of control

Stress scale

  • over-aroused, tense
  • unable to relax
  • touchy, easily upset
  • irritable
  • easily startled
  • nervy, jumpy, fidgety
  • intolerant of interruption or delay

The instructions were as follows: the participants are to complete the questionnaire two days before the exam and on the first day of the block 1 exam (pre-block exam) and on the second day of block 1 exam and two days after the second day of block 1 exam (post-block exam). We repeated the same steps for each block. We then collected data for each block exam for a total of 6 blocks. We then entered the data into Excel spreadsheets. When the data were all entered into the Excel spreadsheet, we then split the questions according to the Depression, Anxiety and Stress Scale (DASS) scale, divided all the questions according to pre-block exam and post-block exam.

RESULTS

In each study the levels of depression, anxiety and stress of the student’s pre examination period were significantly higher than the post examination period.

For block 1, there were a total of 115 students that were surveyed for the pre examination period and only 86 of those students completed the survey post examination.  We utilized the DASS to measure the three factors in question. This scale ranged from normal, mild, moderate, severe, to extremely severe. The breakdown percentages of the students are presented in Graphs and tables (1,4,8,11,15,18). We used a two-tail paired t-test to determine the significance of our data. For the block 1 examination period, there is significant Anxiety p-value of 0.019 (p<0.05), significant Depression p-value of 0.021 (p<0.05), and significant stress p-value of 0.013 (p<0.05).

For block 2, there were a total of 102 students that took the survey in the pre examination period and only 82 of those students completed the survey post examination, the breakdown percentages of the students are presented in graphs and tables (2,5,9,12,16,19). Again, we determined the significance of our data utilizing a two-tailed paired t-test. For the block 2 examination period, there is significant Anxiety p-value of 0.031 (p<0.05), significant Depression p-value of 0.018 (p<0.05), and significant stress p-value of 0.034 (p<0.05).

For block 3, there were a total of 56 students that were surveyed for the pre examination period and only 37 of those students completed the survey post examination, the breakdown percentages of the students are presented in graphs and tables (3,6,10,13,17,20). We determined the significance of our data using a two-ailed paired t-test. For the block 3 examination period, there is significant Anxiety p-value of 0.019 (p<0.05), significant Depression p-value of 0.029 (p<0.05), and significant stress p-value of 0.045 (p<0.05).

Click here to view results graphs and tables

Discussion

This study was set out to investigate the prevalence of stress, depression, and anxiety in medical students. Researchers analyzed the St. James School of Medicine student population. Over two semesters, we measured the three factors in question utilizing the DASS diagnostic test. Our null hypothesis for this study indicates there will be no difference in stress, anxiety, and depression levels before block exams, and after block exams. Our alternative hypothesis indicates there will be a difference in these factors before the exam and after the exam. However, with a p-value lower than .05 for each measured variable, in each block, we as a team decisively rejected the null hypothesis. These medical students showed a significant increase in stress, depression, and anxiety in the pre exam period as compared to the post exam period.

Our findings demonstrated a significant increase in stress, anxiety, and depression in the pre exam period and this can be explained by the following reasons. St. James divides each semester into four blocks. Each block accounts for approximately 25% of the student’s final grade. Each individual block consists of student activities, presentations and quizzes that typically account for 30% of the block grade. The remaining 70% consists of the block exam grade. Essentially, this means a student can do really well in the student activities, quizzes, and presentations, and enter the exam with a score of 27 out of a total 30. However, the block exam accounts for 70% of their total grade, so even if a student went into the exam with an A, and their block exam score was 50%, this hypothetical student would end up with a final block score of 77%.  Equivocally, this student’s grade dropped from an A to C in one test; that is a decrease in two letter grades. For the average grade-driven medical student, this reality is devastating. This realization increases the student’s stress, depression, and anxiety levels quite substantially. This partially explains why our research team found significant results for each variable measured in each block.

The majority of medical students places academic performance as their primary focus. St. James academic format allowed the research team an effortless means of investigating emotional changes based on academic performance. Essentially, this institution places their students in a situation in which the majority of their grade, and academic success, depends on their performance on one single block exam. So basically because of this format, our research team was left with the simple task of measuring the levels of the three variables in the students before the major exam and measuring them over. The results were clear. The block exam that weighed so heavily in their final grade induced significant levels of stress, depression, and anxiety. Our research study of these three variables was perfectly suited for such an academic format.

Our results of this study confirm the findings of previous studies investigating medical students stress, depression, and anxiety; the most notable study was the research conducted by Rosenthal and Okie (2005). They interviewed medical students at Harvard and Duke Medical schools. They found that roughly 40% of the students suffered from moderate to severe depression. Our study, involved around 50% of the St. James student population and about 40-45% of the students suffered from some form of depression pre exam more so than post exam. On the other hand, research from Treadway and Chatterjee  (2011) took more of an individualistic approach and got personal accounts of medical students experience; not just in medical school, but also being in the hospitals during clinical rotations. This journal article recited many of the stresses, anxieties of medical students, mainly in their third and fourth years of study.  Treadway and Chatterjee’s paper postulates that the majority of stresses, and anxiety a medical student suffers from occur in the third and fourth years of their medical education. The research performed in our study only investigated students in their first year and a half of education. With that being said, we were still able to witness the significant prevalence of stress, depression, and anxiety within the student population. Future research of our study can investigate third and fourth year students stress, anxiety, and depression levels via an online survey. Then, we can compare the levels of the three variables in the third and fourth year students to those of the students in Anguilla to see if there truly is increased levels of stress and anxiety in the senior students. These results can then be compared to Treadway and Chatterjee’s research (2011).

Up to this point, the majority of research attributes emotional disturbances to the situation. But pioneer research from Fricchione also acknowledges the presence of a genetic variant in the serotonin transporter gene, which may predispose some people to increased levels of depression and anxiety (2004). Although these findings from Fricchione are still in its infancy stage, this may answer the question whether or not these stresses, depression and anxiety are hereditary. Taking this into consideration, future research of our study can inquire from students that had increased stress levels if any of their family members also suffer from significant stress, depression, and anxiety. Although it is outside the scope of our research to analyze the genetic basis of these three variables, by simply asking the question whether the family members also suffer from similar conditions, will provide us researchers with at least a correlation or link to family members. This will be a valuable means to support or refute Fricchione’s theory on the genetic basis of inheritance of these factors.

There were some unexpected results found during our data collection. There were a handful of the population that actually had increased stress, depression, and anxiety levels after the block. Although this was a small population, these findings still warrant an explanation. These students may have felt more confident before the exam because they may have scored really high in the previous block, or even went into the exam with an ‘A’, and then after the exam their performance was not what they expected and this dissonance between what they actually scored and what they expected to score may have increased their stress, depression, and anxiety levels. Nevertheless, these findings surprised the researchers because this possibility was not even considered during the research period.

There were a few issues with this study that lends itself to criticism. Most notably, this study was conducted over two semesters, it was supposed to encompass a total of seven blocks because during the eighth block the researchers were expected to present their findings. However, during the course of data collection, block 4 data of semester 1 was lost. Through this error, we cannot quantitatively substantiate our findings for this block. But taking our previous findings into consideration, it may be justified to assume that the block 4 semester 1 data would closely resemble that of the other six similar blocks of data. Strictly speaking, this assumption cannot be made without statistical analysis. In addition, within each block analysis, there was a 10-15% attrition rate. Meaning that there were a percentage of students that took the pre exam survey and failed to take the post exam survey. This also may have impacted the results minutely. However, our sample size in each block was large enough that these discrepancies should not have any quantifiable impact on the outcome of the results.

Finally, it must be noted that research conducted in this current study was a continuation of a previous study in the semester prior. In that study, the researchers also found are a significant increase in stress, depression, and anxiety levels. Although those previous findings would strengthen our findings in this current study; the previous study is sort of a miniature of the current study. The prior study used DASS as did our current study. But they only used 21 out of a total 42 questions on the scale; which means that they were missing half of the data points used to evaluate the three factors in question. So this alone, may render the previous study incomplete. Statistically speaking, their calculation methods were different than ours. We utilized a two-tailed paired t-test. They utilized a one tailed t-test.  This key difference makes the two sets of data incompatible. It would be considered a statistical error to fuse both sets of data into one study. With respect to real-world application both sets of data can be used, however, to demonstrate the emotional impact of the three measured variables on medical students. So we can still acknowledge their findings with our findings, but for strict analysis, it must be noted that their process was different than our process.

Below is a graph comparing both studies together, the depression levels in the previous studies are quite similar to the results we have in our current study.. Below the chart is a table clearly showing the percentages of students that were in each category.

graph1

These statistics are so strikingly similar that it seems they derived from the same study. Nevertheless, these are the results for depression. We now turn our attention to stress and anxiety to determine any similarities in results.

Severity of Depression Pre-exam Previous Pre-exam Current Post-exam Previous Post-exam Current
Normal 55.50% 51.52% 65.20% 75.76%
Mild 12.70% 12.12% 10.10% 6.06%
Moderate 12.70% 12.70% 8.70% 3.03%
Severe 2.70% 6.06% 1.40% 9.09%
Extremely Severe 16.40% 15.15% 14.50% 6.06%

These two data sets are also very similar to each other only varying from 2-8%. These results indicate that the findings in our current study are not necessarily random or an anomaly of any kind. The levels of depression, stress, and anxiety seem to be constant across the boards. Finally, we look at the stress variable over the past two studies to see if there are any similarities or differences.

When analyzing all three sets of data from the previous study and comparing it with the present study it becomes apparent that each set of data are very similar to each other, and at some data points it is almost a complete match. It is worth mentioning that in the previous study the academic format was the same; which means students had to take a single exam worth 70% of their block grade. This pressure induced increase stress, depression, and anxiety. The previous study had similar conditions to our current study. The previous research team landed identical results to our current research. This strengthens the validity of our results. Through our statistically significant findings and that of the previous study, our research team can safely postulate that due to the pressure of the block exam, a significant population of students at St. James School of Medicine suffer from increase stress, depression, and anxiety during exam time.

Through this study and future research thereof, we can now find ways to implement and improve the mental health of medical students.  Through Rosenthal and Okie’s research Duke and Harvard implemented an online anonymous web chat for medical students. To ensure the safety of students, the school’s psychiatrist monitored this web chat. If a student posted threatening messages to him or herself, or others the psychiatrist would take the appropriate measures to evaluate the student. This program significantly reduced the stress, anxiety, and depression levels of the student population. Although as doctors, they will face many stressful trials and tribulations, medical students stress, depression, and anxiety levels should be within a healthy range. Because after all, if you cannot maintain your own sanity, how can you maintain that of others? When taking all the aforementioned points into consideration, our results decisively demonstrated that medical students at St. James School of Medicine increase stress, anxiety, and depression before taking block exams. Our results were further supported upon comparing and contrasting our results with the results of the semester’s prior. Both sets of data were so similar that they seemed to be derived from the same study. There may be many other factors that play into the why medical students were stressed, depressed, and anxious; however, the main cause can be attributed to the academic format of St. James School of Medicine. These students are put into a situation in which they are taking one single test that is essentially worth 70% of their block grade. Medical students realize the importance of academic performance and being a successful doctor. So the pressure to perform on this single exam has shown to significantly increase stress, depression, and anxiety levels in these medical students.

grsph2

Severity of Depression Pre-exam Previous Pre-exam Current Post-exam Previous Post-exam Current
Normal 61.80% 66.67% 75.00% 82.05%
Mild 8.20% 12.82% 4.40% 2.56%
Moderate 10.90% 10.26% 5.90% 10.26%
Severe 14.50% 7.69% 11.80% 2.56%
Extremely Severe 4.50% 2.56% 4.40% 2.56%

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