The main goal and objective of medical curriculum is to provide competent and safe doctors to the community. However, mental illness among medical students has often been swept under the carpet and under-recognized, though the rates of these mental illnesses among this vulnerable population are by no means trivial. Therefore, the main aim of the present study was to determine the prevalence and severity of depression, anxiety and stress as well as coping strategies used by medical undergraduate students, enrolled in Arsi University.
The overall prevalence of depression, anxiety and stress symptoms were 52.3%, 60.8% and 40.4% respectively. The reason might be medical students are overloaded with a tremendous amount of information with limited time for internalization, new study environment with obligations to succeed especially during preclinical encounters. This greater degree of workload creates feeling of distress and disappointments that predisposes students to have difficulties in solving problems, impaired judgments; absenteeism from class lesson and break their mental stability. Actually, our present finding is almost similar to the prevalence reported by Basudan et al22, and Iqbal et al23. Conversely, it is higher than study report of Shamsuddin et al24, and Moutinho et al25. This difference could be due to difference in cultural perception of stressful factors, economic burden, very high tuition fees, lack of family support, and higher or lower ‘readiness’ to report different complaint. In our present setup, academic counselling is not a common practice which may be also a contributor.
The proportion of respondents who had extremely severe symptoms of depression, anxiety and stress were 6.2%, 16.2% and 2.3% respectively. This prevalence was similar with finding of Patil et al26. However, it is inconsistent with study result of Gan et al27 and Al-Ani Radeef and Ghazi28. Discrepancies stemming from methodology and type of questionnaire used, could account for this high prevalence obtained by the aforementioned authors. The other possible reasons for the variability could be due to certain differences in the curricula, teaching facilities, qualification and experience of the instructors, and levels of care given to the students.
In this cross-sectional study we correlated sociodemographic risk factors of the student (as independent variables) with the prevalence of depression, anxiety and stress level amongst the undergraduate medical students of Arsi University. In our study, students living in non-dormitory have considerably higher degree of depression, anxiety and stress, which infers living in dormitory, came out to be protective. This finding is in line with study reported by Rab et al29 and Shendarkar30. However, it is inconsistent with study report Kunwar et al31 and Liaqat et al32. This unequivocal distribution tells us that probably depression, anxiety and stress are associated with a multitude of factors such as poor dormitory conditions, more economic stress, distance from the family, less structured environment, and problems dealing with roommates, which might be different or parallel in the two study groups under consideration.
Medical students who had lower monthly income were more likely depressed and stressed. Despite the fact that food and dormitory services are provided to the students by the university, students need money for excursions, to print hand outs, to buy dressings, and other basic necessities11. This indicates that financial constraints could be an additional source of depression, anxiety and stress besides academic stressors. However, other studies have noted no difference33. Again, sample size differences may possibly account for these different results. The same stressors may be perceived differently by different medical students, depending on their cultural background, personal traits, experience and coping skills34. The educational system also plays an enabling role subsequently leading to increased stress levels experienced by students.
There was a significant association between students’ academic year and level of anxiety and stress. Many studies have shown higher stress levels and a higher prevalence of stress-related illnesses among 2nd year medical students as compared with other academic years11,35. On the other hand, senior students developed skills of how to manage stress and stress-related illness than students in the early years36. The possible reason could be the amount and complexity of the material to be learned in the second year with progressive assessments of anatomy, physiology, and biochemistry that they have to pass to join the next higher level. Additional supportive evidence is high level of stress and stress-related illness can be attributed by course workload, lack of leisure time, shortage of learning materials, and frequent examinations.
It has been proven that coping mechanisms are essential for individuals perceiving stress. Coping strategies refer to specific efforts, both behavioral and psychological, that people employ to master, reduce, tolerate, or minimize stress due to undesired events37. Effective and appropriate coping strategies may minimize the impact of encountered stressful situations on one’s well-being. The strategies that the students identified for coping with stress covered almost all the categories reported previously. ‘Active coping’ means taking action or exerting efforts to remove or circumvent the stressor, while ‘Acceptance’ means accepting the stressful event, ‘Planning’ consists of thinking about how to confront the stressor, ‘Positive’ reframing means making best of the situation by growing from it and ‘Denial’ is an attempt to reject the reality of stressful event and ‘Behavioral disengagement’ means giving up or withdrawing efforts to attain goal13.
In the present study, the widely employed original COPE questionnaire containing 14 domains of coping strategies was utilized in order to assess the most common strategies adopted by respondents. The coping strategies most commonly reported by respondents comprise religious coping, active coping, positive reframing and planning strategies. The main coping strategy adopted by respondents was religion, which was similar with the study by Al-Sowygh38, and Ahmad et al39. This was also reported by Krauss et al40, stated that religious people posed higher level self-control thus they are more able to persist in difficult tasks and life situation. However, our result finding was dissimilar with study finding reported in Malaysia41, and Jordan42. The possible reasons for the variability could be due to certain differences in the curricula, teaching facilities and the levels of care given to the students.
A significant correlation between DAS scores and coping mechanisms was found. In particular, the coping mechanisms of denial, substance use, behavioral disengagement, venting, self-blame were significantly associated to DAS, which have been reported in studies as very adaptive and hasten the recovery from distress38. However, the present study was dissimilar with studies conducted on the United Kingdom and Jordanian medical students, who are using alcohol, tobacco, and drugs as common coping strategies7,8. The possible reasons for the variability could be due to geographical and racial differences.