Background: The undergraduate medical training period is a stressful period. In the recent years, due to growing competitiveness and aspiration for achievement the pressure on the students has increased manyfolds and makes the medical students more vulnerable for developing mental distress and thus contributes to poor academic performance and substance use. So an observational, cross-sectional study was conducted among the undergraduate students in a medical college to study the prevalence of mental distress among the undergraduate students of Medical College, Kolkata, India and to find out the correlation between mental distress and explanatory variables among the study population. Materials and Methods: It was a cross-sectional, observational study among the undergraduate students in a medical college, Kolkata, India and used SRQ-20 for the assessment of mental distress. Result: The prevalence of mental distress was 14.5%. Present occupancy, parent’s occupation, attempt in MBBS entrance examination, students who could not cope with the situation, socioeconomic status, and place of residence were found as risk factors of mental distress. A total of 78% of the explanatory variables could be explained by binary logistic regression analysis. Conclusion: Considering these risk factors, preventive measures should be undertaken to reduce the mental distress and its consequences.
Keywords: SRQ-20, mental distress, undergraduate students
|How to cite this article:
Chatterjee C, Mandal PK, Mallik S, Manna N, Sardar JC, Dasgupta S. A study on mental distress among MBBS students in a Medical College, Kolkata, India. Ann Trop Med Public Health 2012;5:453-7
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Chatterjee C, Mandal PK, Mallik S, Manna N, Sardar JC, Dasgupta S. A study on mental distress among MBBS students in a Medical College, Kolkata, India. Ann Trop Med Public Health [serial online] 2012 [cited 2020 Nov 26];5:453-7. Available from: https://www.atmph.org/text.asp?2012/5/5/453/105131
Due to advancement in life-style and rapid urbanization, the mental health is disturbed by various reasons and mental disorders account for nearly 12% of the global burden of disease. By 2020, it is likely to account for 15% DALY loss from 6.1% in 1993 and expected to become second most important cause of disability in the world.  A study conducted for National Council for Mental Health (NCMH) in India which stated that at least 6.5% of Indian population had some form of serious mental disorder, with no discernible urban-rural differences.  Different epidemiological studies on the prevalence of psychiatric morbidity among school-going children and adolescents have reported a wide variation from 20% to 40%.  But mental health problems of medical students are a neglected domain still now as they do not belong to a particular target population. Healthy medical students are likely to become healthy physicians who can then model and promote healthy life-styles with their patients. Due to the rigorous and extensive training throughout the M.B.B.S. course, adaptive capacities are hampered by psychiatric symptoms and it is well documented in the literature.  Stress that begin in the student period may continue to future life and if adjustments are not made, then inevitably a “correction” will occur, which may take the form of “burnout” or physical and/or mental impairment.  In fact mental disorder among medical students has far-reaching impacts on the student itself in the form of impaired performance, deferment of courses, and dropping out of higher education, on the institution, as it can be a disruptive influence on other students and may place considerable pressure on the institution’s staff and its support, counseling, and medical systems, and on the family and society who often have to support the student emotionally and financially. As the medical students are more vulnerable for mental distress, status of mental health among the medical students and exploration of different factors of mental distress will be key to proper psychological functioning which will help promote well-being and minimize burnout. Very few studies have been done among the particular group in India and there is no published study in Eastern India regarding this issue. So the study was undertaken with the following objectives: to study the prevalence of mental distress among the undergraduate students of Medical College, Kolkata, India and to find out the correlation between mental distress and different explanatory variables among the study population.
|Materials and Methods|
It was a cross-sectional study done among the medical students of Medical College & Hospital, Kolkata, India, the oldest Medical College of Asia and one of the premier institutes in India established in the year 1835. It has been serving the community of West Bengal and the neighboring states of India. This college is the center of excellence for the medical studies in undergraduate and postgraduate level and also in rendering specialized hospital services to the common people. The hospital is well equipped with modern gadget of diagnostic and investigation services and more than 5000 patients a day treated in the outdoor patient department (OPD). There are counseling services for deadly diseases like AIDS, family planning acceptors, and the psychiatry department for specialize service but routinely there is no provision of mental health service for the medical students. From the records it was found that the total number of students in the Medical College was 620. Final year students who appeared in the final MBBS exam were excluded from this study. Considering the prevalence of mental disorder in India as 39.9%,  allowable error 10%, and 99% confidence interval, the sample size came as 389 by Epi Info 3.5.1 version. After adding 10% of the sample for nonresponsiveness, it was decided to collect data from 427 students. A list of total students was prepared from the records and constituted the sampling frame. From this list, the required number of samples was selected by using a simple random sampling technique. After excluding the incomplete proforma, finally 415 samples were analyzed.
Data were collected from the students using a self-reporting questionnaire (SRQ-20) which was designed as an instrument to screen for mental health disorder and found to be a reliable tool for use in different countries and cultures. This SRQ was used in various situations by indigenously conducted studies. , In a study conducted in Poona, India, this tool was validated and found that a score of 10 or more was the most sensitive and specific cut of point to consider as mental distress.  This cut of point was used in this study. Information on sociodemographic and other related explanatory variables was collected separately to find association, if any. After getting the verbal consent the questionnaires were given to the students and the reasons for the study were explained and they were informed about the confidentiality of the reports.
The study design was approved by the ethical and research committee of the institution.
Socioeconomic status was assessed by using a modified B.G. Prasad scale. 
Depending upon the per capita monthly income, BG Prasad developed the scale to assess the socioeconomic status and it was modified time to time. According to this scale there are five classes, classs I-V (class I – ≥ Rs. 3653 and, II – Rs. 3652-1826, III – Rs.1825-1096, IV – Rs.1095-548, V – ≤Rs. 547, based on per capita monthly income in Indian rupees). Data were analyzed using Epi Info version 3.5.1. Associations between dependent variable (CMD) and the explanatory variables (sex, place of residence place of origin, type of family, parents occupation, socioeconomic status, knowledge about vastness of course, ability to cope with syllabus, no. of attempts in entrance examination, inclined to change profession, and suicidal attempt) were assessed by binary logistic regression analysis using SPSS version 18.
A cross-sectional study was conducted to study the magnitude and explanatory variables of mental distress among undergraduate medical students in a medical college, Kolkata, India. The study population comprised 72% males and 28% females. A total of 72.3% belonged to urban origin, 57.6% stayed in hostel, 81% were from nuclear family, 46.7% students belonged to class III socioeconomic status. The major reason for opting MBBS were to serve society (55.2%) and for money (42.9%). A total of 36.9% students opted MBBS as per their parent’s will [Table 1]. [Table 2] shows that prevalence of mental distress was more among the females (20.6%) than that of males (12.1%). The prevalence of mental distress was more among the students belong to socioeconomic class III or more in comparison to the students of socioeconomic classes I and II and it was statistically significant. Mental distress was also significantly more among the students of nuclear family, coming from rural area, hostellers, females, and the students who did not cope with the syllabus [Table 3]. The relationship between explanatory variables and mental distress was analyzed by binary logistic regression [Table 4] and it shows that there was significant relationship between mental distress and present occupancy, parent’s occupation, attempt in MBBS entrance examination, students who could not cope with the situation, socioeconomic status, sex, and place of residence. Among the explanatory variables considered for this study 78% could be explained by logistic regression analysis.
|Table 1: Basic characteristics of the study population (n = 415)
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|Table 2: Sex-wise prevalence of mental distress
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|Table 3: Relationship between explanatory variables and mental distress
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|Table 4: Relationship between explanatory variables and mental distress by binary logistic regression analysis
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The present cross-sectional study conducted in a medical college among the undergraduate students using SRQ-20 which is a cost-effective and reasonably valid measure of both community and individual mental distress and considering cut-off of 9/10, as it was validated and found most sensitive and specific in Indian context, revealed that prevalence of mental distress was 14.5%. Our results were consistent with findings of 12.2-15.7% prevalence of mental disorder in a community-based study at Dhaka  and among the young male university students.  In contrast to our study low prevalence of mental distress around 5-7% among Vietnamese refugees in the Western countries  and Australia  was reported. Higher prevalence of mental distress was observed among the medical students at Tehran  and São Paulo, Southeastern Brazil.  In another study conducted in India where 18% prevalence of psychological distress was found among low-income urban women, using a relatively low cut-off score (7/8). It reveals that prevalence of mental disorder was varied in different studies. The reason might be that the studies conducted in different settings and different groups of population, scale used and cut-off point considered for assessing mental distress was not same in all these studies. It might also be due to the differences in the infrastructure of medical colleges where the studies were performed have a direct effect on the teaching-learning process and consequently on the prevalence of mental distress and influences of genetic and behavioral factors prevailing at different places.
Univariate as well as binary logistic regression analysis was done to find out the relationship between mental distress and different explanatory variables.
We observed that prevalence of mental distress was significantly more among the female students in comparison to male students. Similar to our study it was reported that women had proportionately higher rates of stress and depressive symptoms in both the general population and the population of students of medicine. , Fisher et al. also found that female students had increased levels of depression, anxiety, and phobias compared with their male counterparts.  Similarly in the study at Japan  it was observed that female students had more likely to demonstrate increased levels of psychological symptoms using a range of measures compared with their male colleague. Being female, the environment and social support they exposed in most cultures might be caused for higher prevalence of mental distress among the females. However in a study among first year medical students Guthrie et al. did not find any significant difference of psychological morbidity between men and women.  In our study, mental distress was found significantly more among the students belonging to middle or low-income group (class III-V). Several studies conducted in developing countries also demonstrated that, in particular, low income were associated with common mental disorder. ,, Among the lower income group, stress for basic survival and among the middle income group the threat of losing their status due to the gradual flattening of the middle class might be contributed for mental distress. Students from less privileged backgrounds attending the MBBS course were less protected from the vagaries of life and they are more prone to suffer mental ill-health. Roberts et al. also reported that financial problems were associated with poorer mental health in student populations.  The present study showed that mental distress was associated with the students who got admission in the MBBS course appearing more than one attempt in the entrance examination. Rosenthal et al. also reported that high-stakes examinations, such as the part I examination of the National Board of Medical Examiners  and tests that must be passed before academic advancement, frequently lead to performance anxiety. Poor academic performance was a contributory factor for developing mental distress. Mental disorders cause a decrease in concentration and consequently in memory, undermining the learning process and being responsible for low academic performance, thereby creating a vicious cycle that may contribute to a performance phobia.  We found in our study that mental distress was associated with the students who had come from rural areas and presently residing in the hostel. The students who reside in the hostel are faced with the challenges of being uprooted from family and friends and demanding new learning environment might contribute for development of mental distress. In a study among Canadian undergraduates Adalf et al. also reported homesickness was associated with mental health problems. 
We also analyzed other factors like vastness of syllabus and student having profession other than study but no association was observed between mental distresses with these factors.
Since the study was cross-sectional, it analyzed simultaneously outcome and exposure hence the risk factors identified in this study was mere association only, not causal one. Among the explanatory variables considered for this study 78% could be explained by binary logistic regression analysis. There may be other factors for mental distress, which were not identified in this study. SRQ was used to measure the mental distress. It does not provide a specific psychiatric diagnosis, nor does it measure the degree to which help-seeking behavior occurs in response to these symptoms. Future analytical or follow-up studies involving large sample using categorical classification diagnostic system would be able to do a specific psychiatric diagnosis and explore the different causal factors in a better way. In spite of such limitation, the study has some positive findings. The study reveals that mental distress is a problem among medical students and we have identified present occupancy, parents occupation, attempt in MBBS entrance examination, students who could not cope with the situation, socioeconomic status, sex, and place of residence as risk factors of mental distress. The summary result was shared with the college authority. To address individual problems we referred screen positive students to psychiatry OPD for a thorough evaluation. Risk factors identified in this study could be used as a marker for future studies, aware the medical educators to reformulation of the curricula and the teaching-learning process and thus help medical schools to develop and evaluate programs to support students to avoid impairment of their mental health, minimize burn out and promote student well-being.
Principal Medical College, Kolkata, Medical superintendent cum vice principal and all the students.
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Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4]