MENTAL HEALTH OF MEDICAL STUDENTS
Assessing the Mental Health of Medical Students: using the SelfReporting Questionnaire-20
Sara Habib1, Ali Haroon1, Hafsa Paracha2, Gulshan Bano3
1
M.B.B.S., Ziauddin University, 24th year M.B.B.S. Dow University of Health Sciences, 3MSc.
Epidemiology and Biostatistics, Senior Instructor, Dow University of Health Sciences.
Corresponding author:
Dr. Sara Habib
Address: 58-C, block 6, PECHS
Karachi
Pakistan
E-mail: saraasra@hotmail.com
Contact Number: (92)3452252754
Word count: 3544
Abstract word count: 222
Total number of tables: 3
Total number of figures: 1
Conflict of interest declaration: The authors report no conflict of interest.
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MENTAL HEALTH OF MEDICAL STUDENTS
ABSTRACT
Introduction: Common mental disorders (CMD), including anxiety, depressive and
somatoform disorders, are known to have a high prevalence amongst medical students.
Objective: to determine the frequency of common mental disorders amongst Pakistani
medical students.
Methods: A cross sectional study was conducted amongst medical students from a
private and a public medical college. Participants (n=500) were assessed using Self reporting
questionnaire -20 . Total scores were calculated to determine prevalence. Chi-square test was
used to find association between demographic variables and CMD.
Results: The prevalence of CMD among medical students was calculated to be 38.3%
(n=179). The average score was 6.21 ± 4.39 (median: 6; mode: 4). Prevalence of CMD was
significantly more (p=0.017) in students of private medical college (44.8%) than students of the
public medical college (32.4%).
Conclusion: There was a significantly higher prevalence of CMD among the students
enrolled in the private medical school than the students of the public medical school.
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MENTAL HEALTH OF MEDICAL STUDENTS
Assessing the Mental Health of Medical Students: using the Self-Reporting
Questionnaire-20
INTRODUCTION
Health care is a stressful profession. With the honor it entails, it also brings along a lot of
hard work, sleepless nights, desire to be perfect and a will to be the best. Medical students pass
through numerous stressful experiences ranging from excessive study load to frequent contact
with death in an endeavor to become a high-performing doctor [1]. Hence, the students pass
through a complex and multifaceted process throughout the academic years of medical school,
which are not only contingent on the academic environment but also on the student’s ability to
react appropriately to various situations during learning and patient-care training [2].
Literature indicates a high prevalence of common psychological disorders among medical
students, doctors and other healthcare professionals globally [3-10]. A study conducted in an
emergency unit concluded that physicians working for more than 10 years had high depression
(18.4%) and anxiety (26.3%) scores [11]. In another study, it was observed that 30% of doctors
were depressed just after a year of graduation [12]. Furthermore, a study in Brazil identified
42.5% of medical students were suffering from anxiety, depression and somatoform disorders
[13]. In Turkey, a study indicated that 47.9% of the second-year medical students experienced
emotional disorders, which was significantly higher than the students of economics (29.2%) and
physical education (29.2%) [14].
Common mental disorders include anxiety, depression and somatoform disorders [15].
These disorders presents as vague symptoms such as fatigue, irritability, difficulty concentrating,
insomnia and somatic problems [5, 13]. Although anxiety, depression and somatoform disorders
may seem trifling initially, they can predict negative health events later in life. The Harvard
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MENTAL HEALTH OF MEDICAL STUDENTS
Study of Adult Development was conducted on physically healthy young men for nearly 40 years
and concluded that mentally healthy individuals do not deteriorate in physical health as quickly
as do those in poor mental health [16]. This observation indicates that poor mental health of the
medical students could affect not only their personal lives and physical health, but can also
compromise patient care in future as physicians [17, 18].
Studies on Pakistani medical students focus on anxiety and depression, or on substance
abuse [19-21]. Despite increasing literature, to the best of our knowledge, none speak of CMD
collectively. Considering the negative impact of CMD on personal lives [13] and patient care by
the physicians, this study was designed to determine the frequency of common mental disorders
among Pakistani medical students studying at a public and a private university.
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MENTAL HEALTH OF MEDICAL STUDENTS
MATERIALS AND METHODS:
1. Settings:
The study was conducted in 2 medical colleges of Karachi, Pakistan. The Ziauddin
Medical College, a branch of Ziauddin University being the private institute; and Dow Medical
College, a branch of Dow University of Health Sciences (DUHS) serving as the public institute.
2. Ethical consideration:
The ethical approval for this study was taken from the Ethics Review Committee of the Ziauddin
University (ERC ZU) and was approved in September 2012 (Reference number:
0550812SHPSYC).
3. Study design and sampling:
This study was a cross-sectional study, conducted during the months of March 2013 to
May 2013. The medical students enrolled in the first to fifth year of medical colleges of Ziauddin
University and Dow University of Health Sciences were invited to participate in the study.
Random sampling technique was used for sampling by picking a roll number at random on the
attendance sheet of the medical college and then selecting alternating roll numbers as potential
participants. The participants were then approached in their respective class rooms on the basis
of their selected roll numbers.
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MENTAL HEALTH OF MEDICAL STUDENTS
4. Research instruments
The study participants were administered questionnaires comprising of two sections. The
first section inquired about the demography of the participant i.e. age of the participant, gender,
marital status and year of schooling. The second section consisted of the Self-Reporting
Questionnaire – 20 (SRQ-20),
SRQ-20 is an instrument designed by Harding et al for the World Health Organization
(WHO) to screen the prevalence of CMD in developing countries [22, 23], and it has been
validated in Pakistani population [24]. It screens for CMD through a set of twenty ‘yes’ or ‘no’
questions, wherein four questions are concerned about physical symptoms and sixteen questions
about psychological-emotional disorders [25]. The questions were answered considering how an
individual felt in the past 30 days.
5. Data collection
The students were approached in their classrooms at the end of their academic day. At
least two authors were present in the classroom at the time of distribution and collection of the
questionnaires. Informed consent was given to the students which contained details of the study.
All queries by the students were answered. Written consent was obtained before administering
the questionnaire. Students who reported having already seeking psychiatric treatment or those
who were not willing to give signed consent for participation were excluded from the study.
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MENTAL HEALTH OF MEDICAL STUDENTS
6. Data Analysis
The data was analyzed using the SPSS version 17. Common mental disorders were
identified using the WHO’s SRQ-20. Every “No” to a symptom was given a score of “0”
(absent) while every “Yes” was scored “1” (present). Total score was then calculated for each
candidate. The cut-off points among male and female students were established in accordance to
those demonstrated by Mari and Williams, 1986 i.e. scores ≥6 for males and ≥8 for females,
established a sensitivity and specificity of 89% and 81% respectively [11].
Prevalence of CMD was calculated with its measures of distribution. Chi-square test was
applied to find associations between demographic variables and CMD.
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MENTAL HEALTH OF MEDICAL STUDENTS
RESULTS
The number of participants approached from the target population was 500 medical
students, of which 467 consented to participation, making a response rate of 93.4%. This
comprised of 47.8% students enrolled in private medical school and 52.2% enrolled in public
medical school. Out of those who consented, 3 participants (0.6%) were excluded from the
analysis because they were already seeking psychiatric assistance, and further 5 participants
(1%) were excluded due to failure of providing a complete questionnaire. The demographics of
the participants are shared in Table 1.
The prevalence of CMD among the medical students was calculated to be 38.3%
(n=179). The average score was 6.21 ± 4.39 (median: 6; mode: 4). The prevalence of CMD
among medical students of private medical school was 44.8% while among the medical students
of public medical schools was 32.4%. This difference was statistically significant with a p-value
of 0.017. Figure 1 illustrates this distribution of SRQ-20 score. Age, marital status and year of
schooling were not associated with CMD as demonstrated in Table 2. The most commonly
reported symptoms by the participants were “frequent headaches” (52.9%) and “feelings of
nervousness tension or worry” (52.7%). More than half of the population also reported being
“easily tired” in the past 30 days. Frequencies of symptoms reported by participants are shown in
Table 3.
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MENTAL HEALTH OF MEDICAL STUDENTS
Characteristics
Total participants
Type of Medical School:
Public
Private
N
467
%
100
244
223
52.2
47.8
Age:
≤19
20-22
≥23
112
270
85
24
57.8
18.2
Gender:
Male
Female
139
328
29.8
70.2
Marital Status:
Single
Married
459
8
98.3
1.7
Year of Schooling:
First year
Second year
Third year
Fourth year
Fifth year
94
94
98
90
91
20.1
20.1
21
19.3
19.5
Table 1: Demographic distribution of studied population.
N= Number of participants, %= Percentage of participants
9
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MENTAL HEALTH OF MEDICAL STUDENTS
Variable
Type Of University
Private
Public
Year Of Schooling
1st Year
2nd Year
3rd Year
4th Year
5th Year
Marital Status
Single
Married
Gender
Male
Female
Age
<19
20-22
>22
CMD present
% (n)
CMD absent
% (n)
p-value
42.6(95)
32.0(78)
57.4(128)
68.0(166)
0.017
43.6(41)
31.9(30)
40.8(40)
40.0(36)
28.6(26)
56.4(53)
68.1(64)
59.2(58)
60.0(54)
71.4(65)
37.3(171)
25.0(2)
62.7(288)
75.0(6)
0.477
41.7(58)
35.1(115)
58.3(81)
64.9(213)
0.173
39.3(44)
38.5(102)
29.4(25)
60.7(68)
61.5(166)
70.6(60)
0.162
0.270
Table 2: Association of demographic variables with the presence of common mental
disorders.
n= Number of participants, %: Percentage of participants
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MENTAL HEALTH OF MEDICAL STUDENTS
Questions
Frequency answered “yes”
%
Do you feel nervous, tense or
worried?
247
52.9
Do you often have headaches? 246
52.7
Are you easily tired?
239
51.2
Do you find it difficult to
make decisions?
201
43
Do you feel tired all the time?
181
38.8
Do you sleep badly?
164
35.1
Do you feel unhappy?
163
34.9
Is your daily work suffering?
156
33.4
Are you frightened easily?
143
30.6
Do you have trouble thinking
clearly?
142
30.4
Have you lost interest in
things?
136
29.1
Do you find it difficult to
enjoy your daily activities?
133
28.5
Do you have uncomfortable
feelings in your stomach?
124
26.6
Is your digestion poor?
119
25.5
Is your appetite poor?
116
24.8
Are you unable to play a
useful part in life?
111
23.8
Do your hands shake?
90
19.3
Do you cry more than usual?
68
14.6
Has the thought of ending
your life been on your mind?
63
13.5
Do you feel that you are a
worthless person?
62
13.3
Table 3: Frequency of symptoms reported by the medical students.
%= Percentage of participants that answered “yes”.
MENTAL HEALTH OF MEDICAL STUDENTS
Figure 1: Distribution of SRQ-20 score in private and public medical schools.
Count = Number of participants.
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MENTAL HEALTH OF MEDICAL STUDENTS
DISCUSSION
The aim of this study was to identify the prevalence of common mental disorders among
the undergraduate medical students of Karachi, which was found to be 38.3%. This result is
coherent with various studies conducted in other countries, for instance, the prevalence of
common mental disorders among medical students of Brazil was 42.5% [13] , Iran 44% [26] and
Ethopia 32.6% [27]. On the other hand, the result of this study can be considered significantly
higher as compared to those of developed countries with only 2.2-14.8% of Cambridge medical
students [28] and 12.9% of Swedish medical students being depressed [29]. The result of this
study is also comparable to the result of a similar study conducted locally, demonstrating 43.89%
of medical students suffering from depression or anxiety in Multan, Pakistan [19]. It should be
noted that higher prevalence rates have been reported for depression by two other studies
conducted in Karachi i.e. 60% and 70% [20, 21].
The instrument employed in this study, SRQ-20, does not only screen anxiety and
depression, but also screens for somatoform disorders which are collectively called CMD [30].
Similar studies pertaining to screening of mental ailments conducted locally have employed
different hospital scales to identify anxiety, depression and substance abuse [19-21]; however we
selected SRQ-20 by weight of its merits. Apart from being simple, easy to understand and
interpret, it has never been before used on Pakistani medical students. Nonetheless SRQ-20 has
been used, validated and applied to different Pakistani populations [31-36]. The validation of
SRQ-20 has been established in Urdu in Pakistani population [24] and it has also been adapted
for cross-cultural use in Pakistan [37].
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MENTAL HEALTH OF MEDICAL STUDENTS
Medical students pass through several stressful phases during the academic years of
medical school. As the students progress through medical school, frequent examinations in a
highly competitive environment as well as bombardment of intricate information is itself
stressful [20]. Apart from the stressors related to medical education, general stressful situations
of life can further add up to their stresses [14], leading to the development of psychiatric
morbidity including anxiety, depression as well as triggering somatoform symptoms. The
students under these demanding circumstances tend to sacrifice their extra-curricular activities
and end up reducing their leisure time in order to survive in the academic competition. Prolonged
periods of stress that are uninterrupted and unmanageable can be detrimental to a student’s health
[38] especially when a coping mechanism is out of reach. The usual coping mechanisms used by
students to deal with everyday stressors included regular exercise, meditation and other
relaxation techniques such as spending time with friends, sleep, music and sports [38]. Not being
able to manage time for leisure can lead to the development of CMD overtime, compromising
cognitive thinking and decision-making eventually affecting the practical life in which the
students steps-in as a doctor.
South Asian culture can be a factor adding to the stresses of a medical student. A study
conducted in India, a neighboring country with a similar socio-demographic status, enlightened
that 99% of the students in a dental college were strongly pressurized by their parents to enroll in
a medical profession, most of them opting for dentistry only because they did not qualify to enter
a medical school. The same study also identified that most students lived with their parents, and
their career decisions were highly influenced by their parents’ choices regardless of the students’
aptitude [39]. Similar situation was also described by other studies reporting that Asian parents
were highly influential on the decisions made by students [40-42]. When compared to the
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MENTAL HEALTH OF MEDICAL STUDENTS
developed countries, studies showed comparatively lower prevalence of CMD, which may be
associated to the observation that the career decisions of those students were driven by selfmotivation or their aptitude [40]. Inability to keep up with a career demanding high level of
competition and a lack of interest may produce a frustrated individual, predisposing to the
development of CMD [43].
Our results display a significantly higher prevalence of CMD among the students of the
private medical school than the students of the public medical school. One of the reasons for the
difference may be that studying in a private institute is considerably costly when equated to the
government-funded public medical schools where financial assistance is easy to acquire and is
affordable for the majority [44]. Pakistan is a third-world country where public medical schools
are preferred more due to much lower fee structures [42]. Financial stress may account for a
significantly higher CMD among students of private medical school.
Gender was not associated with prevalence of CMD in our study, in contrast to studies
carried out in a similar setting which reported higher prevalence of depression in female medical
students as compared to their male counterparts [19]. The reason behind this difference may be
associated to females being more likely to be concerned about their stressful life situations and
hence more likely to report their psychiatric symptoms. This emotional factor may contribute to
over-reporting of symptoms by females [21]. Interestingly, we also came across studies
informing that females experienced lower levels of stress as compared to males [20].
. Most of the studies on medical students were conducted on participants from a single
medical school which limited the generalizability of the results. To alleviate this limitation, the
participants in this study were selected from 2 medical schools, differing in curriculum, fee
structure, and administration. However, some limitations need to be highlighted. This study
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MENTAL HEALTH OF MEDICAL STUDENTS
being a cross-sectional survey cannot establish a cause-effect relationship between factors that
influence the prevalence of CMD. In addition, the data was obtained using self-reporting
questionnaires, which can be a potential source for over-reporting bias. Moreover, our sample
consisted of a higher number of female students which might have skewed results towards the
female gender, as well as under-reported the prevalence of CMD in males.
More researches of the same nature are required to demonstrate variables that lead to
psychological disturbances among medical students. Appropriate adjustments are advised in the
medical school curriculum, by providing ample time for recreational activities or leisure.
Medical students should also be screened for mental disorders annually by their respective
institutions, and those identified to be suffering from a mental disorder should be referred for
psychological counsel. Early identification of anxiety, depression and somatoform disorders is
important as they are treatable [45-47].
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MENTAL HEALTH OF MEDICAL STUDENTS
ACKNOWLEDGEMENTS:
The authors would like to thank Dr. Sobia Haqqi, Assistant Professor, Department of
Psychiatry, Ziauddin University, for her support and supervision, as well as the medical students
of Ziauddin University and Dow University of Health Sciences for their participation in this
study.
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MENTAL HEALTH OF MEDICAL STUDENTS
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