|Year : 2021 | Volume
| Issue : 2 | Page : 122-131
Perceived stress and coping skills in the newly joined medical undergraduate students: An exploratory study from Eastern India
Swapnajeet Sahoo1, Pravash Ranjan Mishra2, Shree Mishra3, Manisha Kar4, Susanta Kumar Padhy3
1 Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Anatomy, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
3 Department of Psychiatry, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
4 Department of Physiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
|Date of Submission||01-Dec-2021|
|Date of Acceptance||16-Dec-2021|
|Date of Web Publication||02-Feb-2022|
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh
Source of Support: None, Conflict of Interest: None
Objectives: To assess the perceived stress and to evaluate the sources of stress, the prevalence of psychological morbidity (if any) and different coping strategies among the newly joined 1st-semester medical undergraduate students. Methodology: A cross-sectional exploratory study was conducted on all the newly joined 1st-year medical students (who had entered 3 months back) at a tertiary care medical college and teaching hospital in Eastern India. Perceived stress and depressive symptoms were assessed on the Perceived Stress Scale-10 (PSS-10) and Patient Health Questionnaire-9 (PHQ-9). A self-designed questionnaire was used to evaluate different premedical entry-level preparation issues and ongoing psychosocial and academic-related stressors. Coping was evaluated on the Ways of Coping Checklist. Results: Ninety-five first-semester medical undergraduate students (mean age − 18.34 ± 0.95 years) who had joined the Institute 3 months back participated in the study. The mean PSS score was 21.56 ± 3.97 and about 85.3% and 11.6% of the students reported moderate and high degrees of stress. Depressive symptoms were reported by 36.8% (PHQ-9 cut-off ≥10). During medical preparation (as rated on a Likert scale of 0–10), the mean rated stress level was 6.84 ± 2.05. Almost half of the students reported facing problems adjusting to the new place and environment (48.4%), facing language problems (11.6%), and unfavorable hostel facilities (10.5%). Under academic stressors – more than half of the students perceived the vastness of academic curriculum as a major stressor as “often” (53.7%) followed by fear of failure in exams (35.8%). Students followed both negative coping strategies (such as escape avoidance coping, distancing, and confrontive coping) and positive coping strategies (self-controlling, seeking social support, planful problem-solving, and positive appraisal). Significant association of depressive symptom score was found with self-controlling (P - 0.012) and seeking social support (P = 0.015) type of coping. Conclusion: A substantial proportion of undergraduate medical students have moderate to high stress at the entry level (just within the months of joining medical curriculum) and about one-third (36.8%) had depressive symptoms. Most of the students reported of using escape–avoidant type of coping while dealing with the ongoing stressors. More focus on improving resilience and positive adaptive coping skills in the initial formative years of medical education to prevent psychological morbidities and burnout in future years of medical education.
Keywords: Depression, entry level, medical undergraduates, perceived stress, stressors
|How to cite this article:|
Sahoo S, Mishra PR, Mishra S, Kar M, Padhy SK. Perceived stress and coping skills in the newly joined medical undergraduate students: An exploratory study from Eastern India. J Mental Health Hum Behav 2021;26:122-31
|How to cite this URL:|
Sahoo S, Mishra PR, Mishra S, Kar M, Padhy SK. Perceived stress and coping skills in the newly joined medical undergraduate students: An exploratory study from Eastern India. J Mental Health Hum Behav [serial online] 2021 [cited 2022 Oct 7];26:122-31. Available from: https://www.jmhhb.org/text.asp?2021/26/2/122/337169
| Introduction|| |
Medical education training has been regarded as one of the toughest and stressful courses and careers worldwide.,, Every year in India, many aspirants appear for various competitive examinations to get into the medical stream. As the number of medical seats worldwide is less than the number of applicants, it is quite tough competition, and only a few get into it. These students can be called the creamy layer of the society who toil too hard to enter the medical curriculum. The preparation for competitive medical examinations is also a very tedious task and many students have to appear for several times (2–3 years) to clear the National Eligibility cum Entrance test (NEET) and various other individual institutes wise competitive examinations (AIIMS, PGIMER, Chandigarh, JIPMER, Pondicherry etc.).
Stress during medical training has been well reported across the world in several studies. Students enter into the medical colleges with lots of hopes and aspirations; however, it has been seen that they are subjected to a great degree of stress due to several reasons which make them susceptible to develop many psychological issues. It has been often seen that during the initial few years of medical education training, students are subjected to different kinds of stressors, such as the pressure of academics with an obligation to succeed, an uncertain future and difficulties of adjusting into the system. Studies have also focused on evaluating stress levels, burnout, and resilience in the 1st year medical students and have reported that there was a gradual increase in perceived stress and burnout levels and decrease in resiliency and overall physical and emotional health by the end of first academic year.,,, Increase in concerns about the environment and medical curriculum and using more avoidant coping strategies were found to predict perceived stress in a longitudinal study in 1st-year medical students in Hong Kong.
Several socio-economical, family, and emotional problems may affect their performance in learning and academics., Excess stress can lead to physical and psychological problems, can lead to substance abuse, low self-esteem,, and can have long-term future health issues. With regard to specific psychological problems, previous studies have reported depression, burnout, and suicidal ideations among undergraduate medical students. Several studies from worldwide have revealed that long-standing chronic stress starting from the initial years of medical education are the predictors of depressive disorders in medical students.,,, The overall crude global prevalence of depressive symptoms or depression in medical students has been reported to be around 28% in two separate meta-analyses (77 studies in one meta-analysis and 183 studies in another)., Further, the common sources of stress in medical undergraduates have been reported to be personal vulnerabilities, academic (such as vastness of syllabus, tests/exams, lack of time, and lack of facilities for entertainment/extra-curricular activities) and psychosocial concerns (such as high parental expectations, staying away from family in hostels, etc.). More recently, these issues have come to the notice of the medical curriculum policy-makers and there is a growing appreciation of the prevalent stresses among medical students.
Due to all the possible above-mentioned problems in the medical undergraduates, studies have tried to examine the students' coping skills. While some studies have found that students using negative coping strategies like getting used to alcohol, tobacco, and other drugs to cope up with their increasing stress,,, others have found students to be using positive coping strategies such as involving in sports, music and hanging out with friends., having positive relationships, involving in spiritual and mindfulness practices, etc.
However, there is a lacuna in the existing literature with regard to the perceived stress by the undergraduate medical students at the entry level into the medical stream and their baseline coping skills. All the available studies have mostly taken into account all undergraduate students in varying years of education and have assessed their stress and coping abilities/skills. Further, after an extensive literature search regarding Indian studies on this aspect of undergraduate medical education, no Indian study conducted so far has tried to evaluate stress and coping skills in newly joined undergraduate medical students. Therefore, the present study was planned with an aim to assess the perceived stress among the newly joined first-semester medical undergraduate students in a central government-funded tertiary care medical college and hospital. In addition, we also intended to evaluate the sources of stress, evaluate the prevalence of psychological morbidity (if any), and explore different coping strategies used by the newly joined medical students. The study hypothesis being newly joined medical undergraduate students would be having less perceived stress and would be utilizing more positive coping skills to overcome stress in the initial part of their medical training program.
| Methodology|| |
It was a cross-sectional exploratory study and all the first-semester undergraduate medical students who had recently joined were assessed once.
Participants and settings
The study was carried out in the All India Institute of Medical Sciences, Bhubaneswar, Odisha, India, in the 1st week of November 2018. The Institute is a central government-funded medical college and hospital, established in 2012 and provided medical services to the eastern part of India. The study was approved by the Institutional Ethics Committee, and written informed consent was obtained from all participants before recruitment in the study. All the students of first-semester MBBS who had recently joined (July–August 2018, i.e., 3 months before the date of assessment) were approached to take part in the study. Those unwilling and did not provide consent were excluded and no coercion of any kind was undertaken for participation, i.e., the participation was voluntary.
We followed a strict coding system to maintain the confidentiality of the students, i.e., nowhere in the questionnaire was the student asked to reveal his/her identity.
We used a self-designed questionnaire to assess various sociodemographic data and qualitative data pertaining to one's perception toward a medical career during preparation and joining into medical stream. Depressive symptoms and perceived stress were assessed by using Patient Health Questionnaire-9 (PHQ-9) and Perceived Stress Scale (PSS); both of which are widely used, well-validated scales. To assess coping, we used the ways of coping checklist (WCC), which is a 66-item questionnaire containing a wide range of thoughts and acts that people use to deal with the internal and/or external demands of specific stressful encounters. WCC is focused on coping processes in a particularly stressful encounter and not on managing styles or traits. The subject is asked to respond on a 4-point Likert scale. Reliability and validity of the instrument in different age groups and different populations have been well established. In addition, it has been previously used in studies assessing coping skills in medical students.
The data collected were analyzed using the SPSS software, version 20.0 (IBM Corp., India). Descriptive statistics were applied. The Chi-square and Student's t-test were used to find any gender differences. Pearson's correlation coefficient was used to find the association between the different variables. P < 0.01 was considered statistically significant.
| Results|| |
The total strength of the first semester students of MBBS was 100. An anonymous day was chosen (when the students were relatively free; no upcoming exam or class). Five students were absent on the day of assessment; therefore, the total sample of this study was limited to 95 students (n = 95) (all students agreed to participate and provided written informed consent).
The mean age of the sample was 18.52 ± 0.75 years (range: 18–21 years), and majority were males (65.3%). More than one-third of the students hailed from the states of Kerala (36.8%) followed by Odisha (17.9%) and Andhra Pradesh (13.7%). Most of the students came from an urban background (61.1%).
Medical preparation-related questions
The students were asked regarding medical preparation. The mean number of years spent in preparation to get into MBBS was 2.05 ± 0.76 years and mean number of attempts to clear the MBBS NEET examination was 1.46 ± 0.69 times. During preparation, the mean rated stress level rated on a Likert scale (0–10) was 6.84 ± 2.05. The majority reported that they had a close family member or parents to be their inspiration to join MBBS (46.3%). More than half of the students (56.8%) had a relative or a parent in the medical profession. Other family members decided the decision to join MBBS in only 14.7% and about one-tenth (11.6%) felt they were forced to take up MBBS. While the mean rated level of sacrifice made in terms of hard work and dedication to enter medical stream was 7.46 (out of 10), about one-fourth (23.2%) students reported of facing financial problems during preparation. More than four-fifths (87.4%) reported joining private coaching centers to prepare for a mean duration of coaching 1.62 ± 0.73 years with mean amount of money spent on coaching being 1, 42, 900 ± 13,080 Indian rupees. Further, more than one-third of the students had ever felt of leaving preparation due to frustration (37.9%) and joining nonmedical stream (47.2%) [Table 1].
|Table 1: Questions and pertinent issues related to medical preparation (preentry level examination phase) (n=95)|
Click here to view
Psychosocial issues related with stress
About 10% (10.5%) of the students had a family member with mental illness and 3.2% had a family history of suicide. While 8.4% of students had a family member dependent on drugs/alcohol, 18.9% of the students had a close family member suffering from chronic physical illness. More than one-third of the students stayed away from their homes for the first time (38.9%); however, about three-fifth of the students (63.2%) had experience staying in hostel before. About one-fifth of the students self-reported of having persistent sleep problems (22.1%). Almost half of the students reported of facing problems adjusting to new place and environment (48.4%), main problem being cited were language problems (11.6%) and unfavorable hostel facilities (10.5%). Other possible reasons mentioned were feeling homesick (9.5%), food problems/incompatibility and climate (each 5.3%), excess academics (4.2%), and inability to make friends (3.2%). Most of the students reported moderate level of adjustment in the new place (mean - 7.24) and were moderately satisfied with the institute's teaching so far (mean - 7.82), but felt quite stressed due to academics (mean - 7.40). Other details are mentioned in [Table 2].
Types of stress and their sources as reported by the students
When the students were asked about different types of stressors they are facing (in the form of academic, psychosocial and health related) on a self-designed questionnaire (with options of never/rarely, occasionally and often), it was revealed that (1) Under academic stressors – more than half of the students perceived the vastness of academic curriculum as a major stressor as “often” (53.7%) followed by fear of failure in examinations (35.8%), competition with peers (31.6%), lack of time for recreation (29.5%), and lack of special guidance from senior batch (26.3%), (2) Under psychosocial stressors – “often” was reported by about one-fourth of students felt there is a lack of entertainment in the institute (26.3%). Other important things to note were that worrying about future (13.7%) and language problems (13.7%) were considered as stressors by the participants. (3) Under health-related stressors – About one-third of the students were displeased with the quality of food available (34.7%) and about one-fourth were unhappy about the lack of exercise facilities in the institute (28.4%). Other details are mentioned in [Table 3].
Perceived stress and depressive symptoms in 1st year medical students
With regard to perceived stress as measured by the PSS; 10 item scale, the mean PSS score of the sample was 21.56 (standard deviation-3.97) and about 85.3% and 11.6% of the students reported moderate and high degree of stress in the last 1 month [Table 4]. Depressive symptoms were reported by slightly greater than one-third of the participants (36.8%), when cutoff of PHQ-9 was taken as 10 [Table 5]. However, as evident from the [Table 4], no significant gender differences were noted in both scores and severity of PSS and PHQ-9.
|Table 4: Perceived stress and depressive symptoms in first year medical students|
Click here to view
Ways of coping with the stress as reported by the students
Coping to these stressors as reported by students was explored by using the WCC. The various domains of the scale and its mean scores are mentioned in [Table 6]. As shown in [Table 5], students followed both negative coping strategies (such as escape avoidance coping, distancing, and confrontive coping) and positive coping strategies (self-controlling, seeking social support, planful problem-solving, and positive appraisal). Higher scores were found in the domain of escape-avoidance coping; however, as evident from the [Table 6], no significant gender differences in different ways of coping were found.
|Table 6: Association between coping styles (ways of coping checklist domains) with perceived stress (perceived stress scale score) and depressive symptoms (Patient Health Questionnaire-9 score)|
Click here to view
|Table 5: Ways of coping (as per the ways of coping checklist) by the students|
Click here to view
Relationship between coping styles with perceived stress and depressive symptoms (Patient Health Questionnaire-9)
As evident from [Table 6], below, it can be seen that depressive symptoms assessed by PHQ-9 had a significant positive correlation with self-controlling (P - 0.012) and seeking social support (P = 0.015). This suggests that those who have higher depressive symptoms either tend to self-control or seek social support (which can be adaptive and beneficial). There was no significant association of any of the coping styles with total PSS score except for the domain of accepting responsibility (positive correlation).
Association between perceived stress with clinical variables and depressive symptoms
As evident from [Table 7], greater degree of perceived stress correlated with higher depressive symptom score (total PHQ-9 score). Higher degree of perceived stress negatively correlated with level of satisfaction, perceived degree of support, and degree of stressful experience of medical curriculum. In addition, higher the PHQ-9 score/depressive scores, lesser was the level of satisfaction with the Institute so far and greater was the perceived degree of stress of medical education so far [Table 7].
|Table 7: Association between perceived stress (perceived stress scale score) with clinical variables and depressive symptoms (Patient Health Questionnaire-9 score)|
Click here to view
| Discussion|| |
The study was carried out to assess the perceived stress and identify various stressors, other psychosocial issues, and coping skills in newly joined first-semester undergraduate MBBS students in a tertiary care college and hospital. We believe that analyzing these variables at the beginning of medical career would help identify the key areas of perceived stress so that appropriate strategies can be planned to mitigate burnout and future psychological issues. It was a cross-sectional study and all due measures were taken to collect all possible data from the perspectives of newly joined medical students.
Various studies from globally on undergraduate medical students have highlighted several psychosocial factors for stress in medical students. As evident from the study findings [Table 1], the medical students were mostly adolescents, who had joined the institute from different parts of the country, i.e., staying far away from their native cities and families. With regard to questions related to medical preparation, which itself had been quite stressful and competitive in the recent years, most of the students reported a mean duration of preparation of 2 years and mean number of attempts to crack the competitive medical examinations bring 1.46 times. These data are crucial to determine the degree of stress which the young adolescents had gone through before joining the medical stream, as it has been seen that stress gradually becomes chronic as the years of preparation increases, which can predispose the students into various psychological morbidities. In addition, a substantial number of students reported their significant others had taken their decision to join medical stream and about 10% reported they were forced to join medical stream. Although the number of participants reporting this is quite low, this can be quite disheartening and can make them vulnerable to perceived stress during the entire medical career. Further, they might not find the stream to be satisfying, which can lead to medical errors and burnout as the years of medical training increase. Further, many adverse situations such as self-harm attempts and suicides in medical students had been reported citing their lack of interest in choosing career options., Other reported issues related to medical preparation include heavy expenditure spent on medical competitive exam preparation from coaching centers and due to repeated failed attempts about two-fifths had reported felt of leaving preparation and joining nonmedical streams [Table 1]. All these findings are extremely pertinent to note that a vast majority of students preparing for competitive exams experience a significant degree of stress during their adolescence, making them vulnerable to developing common mental disorders in future. In this regard, more focus should be given to the medical stream aspirants so to identify vulnerable students and avoid any untoward life-threatening incidents of self-harm and suicide in this special population, which is quite prevalent nowadays.,
Various other psychosocial issues identified in the present study were having persistent sleep problems, facing problems adjusting to new place and environment, language problems and unfavorable hostel facilities, feeling homesick, food problems/incompatibility and climate, excess academics, and inability to make friends [Table 2]. Further, other stressors as revealed by the students include several academic related, psychosocial related and health-related issues [Table 4]. Studies conducted on the final year medical and dental undergraduate students of Nepal had revealed issues with seniors, staying in hostel, high parental expectations, adjustment with roommates, poor facilities for entertainment, competing with peers, length of course, understanding the course, and work overload to be main stressors., Although many of the stressors as reported by present study participants are similar to the findings of Nepalese undergraduate students, suggesting similar socio-cultural and psychosocial issues in both countries, yet few differences can be attributed to the difference in the scenarios in 1st year newly joined students in comparison with final year medical students. Hence, the Institute's student well-being administration should focus on modifying their approach to mitigate the stressors as per the levels of students and these should be tailor-made as per the identified stressors faced by particular batch of students.
The present study revealed that about 85% and 11% of the 1st year students perceived moderate and high level of stress, which is quite significant. While some studies which had assessed stress during undergraduate entry level had reported about 74% stress scores (with about 2.3% students reporting severe stress) and others have reported unfavorable stress in undergraduate medical students ranging from 11% to 20%., Few Indian studies which had evaluated stress in medical and dental undergraduate students had reported mean perceived stress in the range 25.64–30.25,, which is quite high when compared to present study (mean PSS score - 21.56). However, the above-mentioned studies were conducted on all undergraduate medical students (1st year to final year); therefore, it becomes difficult to ascertain the actual level of stress particularly limited to 1st year students (although higher stress had been reported by final-year undergraduate students in both studies). Some studies had reported female undergraduate medical students having a greater degree of perceived stress,, mostly in the inter personal domain, yet the present study do not these findings suggesting sociocultural differences. Further, it can also be inferred that perception of stress levels might not vary between male and female undergraduate students in the initial phase of medical education training.
With regard to depressive symptoms (as assessed on PHQ-9), the present study revealed about one-third (36.8%) of its participants having depression (PHQ-9 cutoff 10). The present study findings are in concordance with the few studies which have evaluated depressive symptoms in undergraduate-entry level., Systematic review of articles that assessed depression in medical students had reported the prevalence of depression ranging between 28% and 66%.,, The present study findings are within the usual range as reported globally. The present study also reported a significant positive association between perceived stress and depressive symptoms, which is an well-established fact (i.e. the relationship between perceived stress and depression is bi-directional), and affects various other factors such as satisfaction with services/teaching, adjustment with new environment, perceived degree of support, etc.
Evaluation of coping was one of the aims of the present study and as evident from the study findings, the students used negative (such as escape avoidance coping, distancing, and confrontive coping) as well as positive coping strategies (self-controlling, seeking social support, planful problem-solving, and positive appraisal). The use of positive adaptive coping has been beneficial in dealing with stressful situations and increases one's ability to cope in adverse situations. Few studies which had evaluated coping in undergraduate students had reported that them to be using less of active coping and less positive reframing, more use of avoidant stress-coping strategies (such as avoiding discussions, building relationships with opposite sex, smoking, etc.) and females using more of emotional coping strategies (self-blame, seeking emotional support, etc.) as compared to male medical students. The present study revealed the use of both types of coping with no significant gender differences in these aspects. These findings can be regarded as preliminary as previous data, particularly focussing coping used by 1st year entry level is very limited.
Other findings of the study in relation to coping were that those having higher depressive symptoms used more of adaptive coping such as self-controlling and seeking social support [Table 7], which can prove to be quite effective and beneficial in the long run and can prevent one from developing psychological morbidities (such as depression and anxiety). However, one need to have a close watch on these key findings as coping abilities vary from individual to individual, are dynamic in nature and depend on multiple psychosocial factors; and hence, positive coping skills needs to be developed and resilience life skills building workshops needs to be conducted by the administration from time to time to enhance adaptive coping in the budding doctors.
We are aware of our limitations, such as small sample size and cross-sectional nature of the study. Further, there can be multiple other stressors that our self-designed questionnaire and scales used might not capture. Despite these limitations, the present study can be regarded as one of the first to assess perceived stress in newly joined undergraduate medical students and had tried to explore various psychosocial stressors from different perspectives (such as medical preparation related, academic related, and depressive symptoms). Further, assessing stress and its various parameters in the students' initial phase of medical career can be regarded as one of the major strengths of the study. Future studies should be carried out with longitudinal study design to determine the nature of stressors and change in coping strategies by the medical students with an increase in the years of medical training. Further, the study findings can aid in developing strategies to mitigate stress and improve coping skills by carrying out student counseling programs by the Wellness clinics run in the institute.
| Conclusion|| |
To conclude, the present study revealed that a substantial proportion of undergraduate medical students has moderate to high stress at the entry level (just within months of joining medical curriculum) and about one-third (36.8%) had depressive symptoms. The undergraduate students reported many stressful issues pertaining to medical preparation prior to joining the medical curriculum and reported facing various types of stressors (academic, psychosocial and health-related) within few months of joining medical education. Further, most of the students reported using escape-avoidant type of coping and many adaptive coping strategies while dealing with the on-going stressors. More focus on improving resilience and positive adaptive coping skills in the initial formative years of medical education is the need of the hour to prevent psychological morbidities and burnout in future years of medical education.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Voltmer E, Köslich-Strumann S, Voltmer JB, Kötter T. Stress and behavior patterns throughout medical education – A six year longitudinal study. BMC Med Educ 2021;21:454.
Hill MR, Goicochea S, Merlo LJ. In their own words: Stressors facing medical students in the millennial generation. Med Educ Online 2018;23:1530558.
Brazeau CM, Shanafelt T, Durning SJ, Massie FS, Eacker A, Moutier C, et al.
Distress among matriculating medical students relative to the general population. Acad Med 2014;89:1520-5.
Sarkar S, Gupta R, Menon V. A systematic review of depression, anxiety, and stress among medical students in India. J Mental Health Hum Behav 2017;22:88-96. [Full text]
Jordan RK, Shah SS, Desai H, Tripi J, Mitchell A, Worth RG. Variation of stress levels, burnout, and resilience throughout the academic year in first-year medical students. PLoS One 2020;15:e0240667.
McKerrow I, Carney PA, Caretta-Weyer H, Furnari M, Miller Juve A. Trends in medical students' stress, physical, and emotional health throughout training. Med Educ Online 2020;25:1709278.
Santen SA, Holt DB, Kemp JD, Hemphill RR. Burnout in medical students: Examining the prevalence and associated factors. South Med J 2010;103:758-63.
Stewart SM, Betson C, Lam TH, Marshall IB, Lee PW, Wong CM. Predicting stress in first year medical students: A longitudinal study. Med Educ 1997;31:163-8.
Chew-Graham CA, Rogers A, Yassin N. 'I wouldn't want it on my CV or their records': Medical students' experiences of help-seeking for mental health problems. Med Educ 2003;37:873-80.
Niemi PM, Vainiomäki PT. Medical students' academic distress, coping, and achievement strategies during the preclinical years. Teach Learn Med 1999;11:125-34.
Melaku L, Mossie A, Negash A. Stress among medical students and its association with substance use and academic performance. J Biomed Educ 2015;2015:e149509.
Styles WM. Stress in undergraduate medical education: 'The mask of relaxed brilliance'. Br J Gen Pract 1993;43:46-7.
Rosal MC, Ockene IS, Ockene JK, Barrett SV, Ma Y, Hebert JR. A longitudinal study of students' depression at one medical school. Acad Med 1997;72:542-6.
Guthrie E, Black D, Bagalkote H, Shaw C, Campbell M, Creed F. Psychological stress and burnout in medical students: A five-year prospective longitudinal study. J R Soc Med 1998;91:237-43.
Dahlin M, Joneborg N, Runeson B. Stress and depression among medical students: A cross-sectional study. Med Educ 2005;39:594-604.
Dyrbye LN, Thomas MR, Massie FS, Power DV, Eacker A, Harper W, et al.
Burnout and suicidal ideation among U.S. medical students. Ann Intern Med 2008;149:334-41.
Abdulghani HM, AlKanhal AA, Mahmoud ES, Ponnamperuma GG, Alfaris EA. Stress and its effects on medical students: A cross-sectional study at a college of medicine in Saudi Arabia. J Health Popul Nutr 2011;29:516-22.
Hiranwong T, Sitthiprawiat P, Siritikul S, Jiwtrakul J, Klaychaiya S, Chaipinchana P, et al
. Mental strength and challenges among Thai medical students in their clinical years-study protocol. Healthcare (Basel) 2021;9:305.
Shaikh BT, Kahloon A, Kazmi M, Khalid H, Nawaz K, Khan N, et al.
Students, stress and coping strategies: A case of Pakistani medical school. Educ Health (Abingdon) 2004;17:346-53.
Puthran R, Zhang MW, Tam WW, Ho RC. Prevalence of depression amongst medical students: A meta-analysis. Med Educ 2016;50:456-68.
Rotenstein LS, Torre M, Ramos MA, Rosales RC, Guille C, Sen S, et al.
Prevalence of burnout among physicians: A systematic review. JAMA 2018;320:1131-50.
Sreeramareddy CT, Shankar PR, Binu VS, Mukhopadhyay C, Ray B, Menezes RG. Psychological morbidity, sources of stress and coping strategies among undergraduate medical students of Nepal. BMC Med Educ 2007;7:26.
Guthrie EA, Black D, Shaw CM, Hamilton J, Creed FH, Tomenson B. Embarking upon a medical career: Psychological morbidity in first year medical students. Med Educ 1995;29:337-41.
Ashton CH, Kamali F. Personality, lifestyles, alcohol and drug consumption in a sample of British medical students. Med Educ 1995;29:187-92.
Miller PM, Surtees PG. Psychological symptoms and their course in first-year medical students as assessed by the Interval General Health Questionnaire (I-GHQ). Br J Psychiatry 1991;159:199-207.
Kaewpila W, Thaipisuttikul P, Awirutworakul T, Jumroonrojana K, Pitidhammabhorn U, Stevens F. Depressive disorders in Thai medical students: An exploratory study of institutional, cultural, and individual factors. Int J Med Educ 2020;11:252-60.
Kroenke K, Spitzer RL, Williams JB. The PHQ-9. J Gen Intern Med 2001;16:606-13.
Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav 1983;24:385-96.
Folkman S, Lazarus RS, Dunkel-Schetter C, DeLongis A, Gruen RJ. Dynamics of a stressful encounter: Cognitive appraisal, coping, and encounter outcomes. J Pers Soc Psychol 1986;50:992-1003.
Sandover S, Jonas-Dwyer D, Marr T. Graduate entry and undergraduate medical students' study approaches, stress levels and ways of coping: A five year longitudinal study. BMC Med Educ 2015;15:5.
Stewart SM, Betson C, Marshall I, Wong CM, Lee PW, Lam TH. Stress and vulnerability in medical students. Med Educ 1995;29:119-27.
Nicholson S, Hastings AM, McKinley RK. Influences on students' career decisions concerning general practice: A focus group study. Br J Gen Pract 2016;66:e768-75.
Coentre R, Góis C. Suicidal ideation in medical students: Recent insights. Adv Med Educ Pract 2018;9:873-80.
Watson C, Ventriglio A, Bhugra D. A narrative review of suicide and suicidal behavior in medical students. Indian J Psychiatry 2020;62:250-6. [Full text]
Bali H, Rai V, Khanduri N, Tripathi R, Adhikari K, Sapkota B. Perceived stress and stressors among medical and dental students of Bhairhawa, Nepal: A descriptive cross-sectional study. JNMA J Nepal Med Assoc 2020;58:383-9.
Atkinson SR. Elevated psychological distress in undergraduate and graduate entry students entering first year medical school. PLoS One 2020;15:e0237008.
Elzubeir MA, Elzubeir KE, Magzoub ME. Stress and coping strategies among Arab medical students: Towards a research agenda. Educ Health (Abingdon) 2010;23:355.
Yusoff MS, Abdul Rahim AF, Baba AA, Ismail SB, Mat Pa MN, Esa AR. The impact of medical education on psychological health of students: A cohort study. Psychol Health Med 2013;18:420-30.
Anuradha R, Dutta R, Raja JD, Sivaprakasam P, Patil AB. Stress and stressors among medical undergraduate students: A cross-sectional study in a private medical college in Tamil Nadu. Indian J Community Med 2017;42:222-5.
] [Full text]
Srivastava R, Jyoti B, Pradhan D, Kumar M, Priyadarshi P. Evaluating the stress and its association with stressors among the dental undergraduate students of Kanpur city, India: A cross-sectional study. J Educ Health Promot 2020;9:56.
Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad Med 2006;81:354-73.
Saxena Y, Shrivastava A, Singhi P. Gender correlation of stress levels and sources of stress among first year students in a medical college. Indian J Physiol Pharmacol 2014;58:147-51.
Hope V, Henderson M. Medical student depression, anxiety and distress outside North America: A systematic review. Med Educ 2014;48:963-79.
Rotenstein LS, Ramos MA, Torre M, Segal JB, Peluso MJ, Guille C, et al.
Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: A systematic review and meta-analysis. JAMA 2016;316:2214-36.
Ghorbani N, Krauss SW, Watson PJ, Lebreton D. Relationship of perceived stress with depression: Complete mediation by perceived control and anxiety in Iran and the United States. Int J Psychol 2008;43:958-68.
Zhang Y, Peters A, Chen G. Perceived Stress Mediates the Associations between Sleep Quality and Symptoms of Anxiety and Depression among College Nursing Students. Int J Nurs Educ Scholarsh. 2018;15. doi: 10.1515/ijnes-2017-0020.
Zvauya R, Oyebode F, Day EJ, Thomas CP, Jones LA. A comparison of stress levels, coping styles and psychological morbidity between graduate-entry and traditional undergraduate medical students during the first 2 years at a UK medical school. BMC Res Notes 2017;10:93.
Abouammoh N, Irfan F, AlFaris E. Stress coping strategies among medical students and trainees in Saudi Arabia: A qualitative study. BMC Med Educ 2020;20:124.
Madhyastha S, Latha KS, Kamath A. Stress and coping among final year medical students. Arch Ment Health 2014;15:74-80. [Full text]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]