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ORIGINAL ARTICLE
Year : 2022  |  Volume : 49  |  Issue : 2  |  Page : 140-147

A study to assess the impact of gender and psychiatric distress on coping responses and the levels of anxiety, depression, and suicidal ideation in undergraduate medical students


1 Department of Clinical Psychology, Ranchi Institute of Neuro-Psychiatry and Allied Sciences, Kanke, Ranchi, Jharkhand, India
2 Department of Physiology, Burdwan Medical College, Burdwan, West Bengal, India
3 Department of Applied Psychology, University of Calcutta, Kolkata, West Bengal, India
4 Department of Community Medicine, ESI-PGIMSR and ESIC Medical College, Joka, Kolkata, West Bengal, India

Date of Submission09-Jan-2022
Date of Acceptance19-Apr-2022
Date of Web Publication23-Aug-2022

Correspondence Address:
Kalyan Kumar Paul
FE-149, Sector III, Salt Lake City, Kolkata - 700 106, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jss.jss_2_22

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  Abstract 


Background: Medical education is one of the most stressful academic curricula across the globe, and response to stress can be manifested as physical response, emotional response, cognitive response, and behavioral response. Aims: The aim was to study the relationships between coping styles, level of anxiety, level of depression, and level of suicidal ideation in medical students with a special emphasis on gender differences. Materials and Methods: This cross-sectional study was conducted on 250 medical students of a medical college in West Bengal. Data were collected using online Google Forms. A pretested structured questionnaire contained five scales, namely General Health Questionnaire-28, Coping Response Inventory, State-Trait Anxiety Inventory, Beck Depression Inventory-II, and Adult Suicidal Ideation Questionnaire. Results: Out of 250 students, 63.6% were male. In the case of psychiatric distress, 57.5% of males and 42.5% of females reported no considerable psychiatric distress. Among those with considerable levels of psychiatric distress, majority (68.6%) were male. Most (88%) of the participants exhibited above-average levels of state anxiety and only 0.8% of them exhibited above-average levels of trait anxiety. Moderate-to-severe levels of depression were found in 39.2% of the participants and 27.6% of them reported frequent suicidal ideation. Majority of the participants utilized avoidance coping methods such as cognitive avoidance, acceptance or resignation, seeking alternative rewards, and emotional discharge (ED). ED was found to be the most frequently used coping response. Conclusions: Psychiatric distress has a significant impact on the levels of depression, anxiety, suicidal ideation, and coping responses in medical students. Gender had a significant role in the case of suicidal ideation and ED in medical students. Emotion-focused coping is more in use among medical students as compared to approach coping or problem-focused coping.

Keywords: Coping skills, medical students, mental health


How to cite this article:
Paul O, Chaudhuri A, Banerjee U, Paul KK. A study to assess the impact of gender and psychiatric distress on coping responses and the levels of anxiety, depression, and suicidal ideation in undergraduate medical students. J Sci Soc 2022;49:140-7

How to cite this URL:
Paul O, Chaudhuri A, Banerjee U, Paul KK. A study to assess the impact of gender and psychiatric distress on coping responses and the levels of anxiety, depression, and suicidal ideation in undergraduate medical students. J Sci Soc [serial online] 2022 [cited 2022 Dec 1];49:140-7. Available from: https://www.jscisociety.com/text.asp?2022/49/2/140/354265




  Introduction Top


Medical education is one of the most stressful academic curricula across the globe. Academic pressure, lack of time for leisure or hobbies, chronic physical and psychological fatigue, and peer pressure are some of the causes that make life more stressful for medical students. Psychological stressors can be either acute or chronic. The response to stress can be manifested in four forms, namely physical response, emotional response, cognitive response, and behavioral response.[1],[2],[3]

Coping consists of cognitive and behavioral efforts needed to manage specific challenges. People usually have to suffer lesser ill effects from a particular stressor if they possess or employ adequate coping resources and effective coping mechanisms. Several researchers have attempted to identify and classify different types of coping techniques used by people in dealing with stress. A variety of coping strategies have been revealed through their work.[4],[5],[6]

Coping methods may be mainly classified into problem-focused coping techniques and emotion-focused coping techniques. Problem-focused coping involves efforts to alter or eliminate a source of stress, whereas emotion-focused coping techniques are aimed at regulating the negative emotional consequences of the stressor. The two forms of coping sometimes function simultaneously as well. Humor and social support may also play major roles in coping. Coping strategies differ from one another concerning their adaptive value. All strategies are not similar or equal. Failure to adopt proper coping strategies may lead to mental health issues.[4],[5],[6]

Stressful life events related to career, family, marriage, divorce, death of a spouse, etc., often lead to depression. Several studies have proved that severely stressful life events often serve as precipitating factors for unipolar depression. This is especially true for young female adults, for whom stressful life events are more likely to show a stronger stress depression relationship than in men. Personality factors also contribute to the causation of depression. People with high levels of neuroticism or negative affectivity are prone to be easily affected by negative emotions such as sadness, anxiety, guilt, and hostility and they get easily flustered by any stressful situation.[7],[8],[9],[10]

The age-standardized suicide rate in India is 16.4 per 100,000 for women (6th highest in the world) and 25.8 for men, ranking 22nd in the world (as per the World Health Organization). Suicide ranks as the third most common cause of death in the US for 15–19 years old (after accidents and homicide), accounting for approximately 11% of total deaths. The increase in the rate of suicide is not exclusive to the US and has been observed in many countries. Suicidal deaths are quite common among Indian adolescents and adults as well. The most vulnerable group was those between the age of 18–30 years and 30–45 years. Symptoms of suicidal ideation may include feelings of being trapped or helpless, feeling intolerable emotional pain, having an abnormal preoccupation with violence, dying or death, mood swings, talking about revenge, guilt or shame, being agitated, being in a heightened state of anxiety, sleep disturbances, elevated consumption of drugs and alcohol, engaging in risky behavior, and lack of concentration.[11],[12],[13],[14],[15]

The medical students will be future doctors and team leaders of health-care management. It is important to find out what kind of coping strategies medical students employ to deal with the huge amount of pressure, expectation, and responsibility that they go through and the consequent levels of generalized anxiety, free-floating worry, depressive illness, and suicidal thoughts or intent, if any. Thus, the present study was conducted to find out the relationships between coping styles, level of anxiety, level of depression, and level of suicidal ideation in medical students with a special emphasis on gender differences.


  Materials and Methods Top


This cross-sectional study was conducted among UG medical students of a medical college of West Bengal over a period of 3 months after obtaining approval of the Institutional Ethics Committee.

Inclusion criteria

MBBS students in the age group of 18–25 years willing to participate in the study were included in the study.

Exclusion criteria

Subjects diagnosed with major psychiatric illness and on medication or with substance dependence were not included.

Sample size

An online sample size calculator was used to calculate the sample size. Since 650 undergraduate MBBS students were studying at the medical college, the sample size calculated was 250 considering a confidence level of 95%, 5% margin of error, population proportion of 50%, and 3% of nonresponders.

Data collection

The present study was conducted online using Google Forms, using a pretested structured questionnaire. There were no direct identifiers in the forms. Faculties of this institution were requested to share these links with their students. The participants were ensured that their information will not be disclosed anywhere. In the first section of the form, the purpose of the study was explained, and informed consent was obtained from the participants. In the second part of the form, participants were asked to fill up demographic details and relevant history; in the third part, participants had to fill up five scales: General Health Questionnaire-28 (GHQ-28), Coping Response Inventory (CRI), State-Trait Anxiety Inventory (STAI), Beck Depression Inventory-II (BDI-II), and Adult Suicidal Ideation Questionnaire (ASIQ).

The scales used for the present study were as follows:

General Health Questionnaire-28

The GHQ-28 is a measure of emotional distress in medical settings and helps in the detection of psychiatric distress about general health.[16]

Through factor analysis, the tool has been divided into four subscales.

  1. Somatic symptoms (items 1–7)
  2. Anxiety/insomnia (items 8–14)
  3. Social dysfunction (items 15–21)
  4. Severe depression (items 22–28).


GHQ-28 is a self-administered questionnaire. Subjects base their responses on the general state of their health or their overall health, in general, over the past few weeks. Although no time limit is given, administration time is usually approximately 5 min. Total scores range from 0 to 28. Each item has four options. The first two options are scored “0” and the last two options are scored “1.”

Coping Response Inventory-Adult (CRI-Adult)

It is a measure of eight different types of coping responses to stressful life circumstances. These responses are measured by eight subscales. The subscales are as follows:

  1. Logical analysis
  2. Positive reappraisal
  3. Seeking guidance and support (SG)
  4. Problem-solving (PS)
  5. Cognitive avoidance (CA)
  6. Acceptance or resignation (AR)
  7. Seeking alternative rewards (SR)
  8. Emotional discharge (ED).


The first set of four scales measures approach coping; the second set of four scales measures avoidance coping. The first and second scales in each set measure cognitive coping strategies; the third and fourth scales in each set measure behavioral coping strategies. The CRI-Adult[17],[18] may be used with healthy adults, psychiatric and substance abuse patients, and medical patients. It is suitable for assessing individuals aged 18 and above. The T-score ranges and equivalent percentile ranges are mentioned in [Table 1].
Table 1: Criteria for interpreting Coping Response Inventory-Adult standard scores

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State-Trait Anxiety Inventory (STAI)

STAI[19],[20],[21] is a self-report inventory. Subjects respond to the questions on a 4-point Likert scale. In Form X-1, subjects are evaluated based on how they feel “right now” or “at this moment.” In Form X-2, subjects are evaluated based on of how they “generally feel.”

Each item of STAI is given a score between 1 and 4. A rating of 4 indicates the presence of a high level of anxiety for 10 state items and 13 trait items. Few items have reversed scoring. In these items, a high score of 4 indicates the absence of anxiety.

Beck Depression Inventory (BDI)

The BDI[22] is a 21-item self-reporting questionnaire for evaluating the severity of depression in normal and psychiatric populations. Self-administration takes around 5–10 min. Twenty-one items are ranked on a scale of 0–3, on the basis of severity, where 0 indicates absence of symptom and 3 indicates severe symptom. Higher scores indicate greater symptoms. In nonclinical population, scores above 20 indicate depression [Table 2].
Table 2: Beck Depression Inventory score

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Adult Suicidal Ideation Questionnaire (ASIQ)

It can be administered on individuals or groups and can be completed in 10 min or less. The scale ranges from 0 (I never had this thought) to 6 (almost every day). The ASIQ[23] is provided to define a level of suicidal ideation which is considered to be clinically relevant and which indicates the need for further evaluations. It is a self-administered scale and the instructions are provided at the beginning of the questionnaire; the participants were asked how they have been feeling these days (past 1 month). Participants need to tick the items applicable to them.

The raw ASIQ total score is obtained by summing the point values of item responses. The maximum possible raw score for ASIQ is 150, with the higher scores indicating more numerous and frequent suicidal thoughts [Table 3].
Table 3: Adult Suicidal Ideation Questionnaire score

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Statistical analysis

SPSS version 20 (© Copyright IBM Corporation & its licensors 1989, 2011) was used to analyze the data, and appropriate statistical tests were applied. For all statistical tests, P < 0.05 was considered statistically significant. Normality of the data was checked before analysis.


  Results Top


The present study was conducted among 250 medical students of a government medical college where 159 males and 91 females participated in the survey conducted online.

In the case of psychiatric distress, 57.5% of males and 42.5% of females reported no considerable psychiatric distress, whereas 68.6% of males and 31.4% of females reported of having considerable levels of psychiatric distress. Overall, 54.8% of the participants (including both male and female) reported to have a considerable level of psychiatric distress. 88% of the participants exhibited above-average levels of state anxiety, although only 0.8% of them exhibited above-average levels of trait anxiety. 39.2% of the participants reported moderate-to-severe levels of depression and 27.6% of them reported frequent suicidal ideation, indicating the need for further suicidal screening. [Table 4] shows the mean score of participants using different scales.
Table 4: Mean score of participants using different scales

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A two-way ANOVA performed to analyze the effect of gender and psychiatric distress on state anxiety revealed that there was no statistically significant interaction between the effects of gender and psychiatric distress on state anxiety (F = 6.43, P = 0.012). Simple main effects analysis showed that gender did not have a statistically significant effect on state anxiety (P = 0.889), but the presence of considerable psychiatric distress did have a statistically significant effect on state anxiety (P < 0.001) [Table 5].
Table 5: Two-way ANOVA to analyze the effect of gender and psychiatric distress on state anxiety

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A two-way ANOVA performed to analyze the effect of gender and psychiatric distress on trait anxiety revealed that there was a statistically significant interaction between the effects of gender and psychiatric distress on trait anxiety (F = 4.74, P = 0.03). Simple main effects analysis showed that gender did not have a statistically significant effect on trait anxiety (P = 0.23), but the presence of considerable psychiatric distress had a statistically significant effect on trait anxiety (P <.001) [Table 6].
Table 6: Two-way ANOVA to analyze the effect of gender and psychiatric distress on trait anxiety

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There was a significant difference in the levels of depression between medical students having considerable psychiatric distress and those not having considerable psychiatric distress. However, there was no statistically significant interaction between the effects of gender and psychiatric distress on depression (F = 0.862, P = 0.354). No significant difference in the levels of depression was found between males and females [Table 7].
Table 7: Two-way ANOVA to analyze the effect of gender and psychiatric distress on depression

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[Table 8] shows that there was a significant difference in the levels of suicidal ideation between medical students having considerable psychiatric distress and those not having considerable psychiatric distress but not with gender variation. There was a significant interaction between the effects of gender and psychiatric distress on suicidal ideation (F = 7.12, P = 0.008).
Table 8: Two-way ANOVA to analyze the effect of gender and psychiatric distress on suicidal ideation

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There was a significant difference in the levels of logical analysis between medical students having considerable psychiatric distress and those without considerable psychiatric distress [Table 9].
Table 9: Two-way ANOVA to analyze the effect of gender and psychiatric distress on logical analysis

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[Table 10] shows that there was a significant difference in the levels of positive reappraisal between medical students having considerable psychiatric distress and those having no considerable psychiatric distress.
Table 10: Two-way ANOVA to analyze the effect of gender and psychiatric distress on positive reappraisal

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There was a significant difference in the levels of SG and support between medical students with or without considerable psychiatric distress. There was also a significant interaction between the effects of gender and considerable psychiatric distress on SG and support (F = 7.835, P = 0.006) [Table 11].
Table 11: Two-way ANOVA to analyze the effect of gender and psychiatric distress on seeking guidance and support

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[Table 12] shows that there was a significant difference in the levels of PS between medical students having considerable psychiatric distress and those not having considerable psychiatric distress (F = 14.83, P < 0.001).
Table 12: Two-way ANOVA to analyze the effect of gender and psychiatric distress on problem-solving

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There was a significant difference in the levels of CA between medical students with or without considerable psychiatric distress (F = 28.81, P < 0.001) [Table 13].
Table 13: Two-way ANOVA to analyze the effect of gender and psychiatric distress on cognitive avoidance

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A significant difference in the levels of AR between medical students having considerable psychiatric distress and medical students having no considerable psychiatric distress was observed [Table 14].
Table 14: Two-way ANOVA to analyze the effect of gender and psychiatric distress on acceptance or resignation

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[Table 15] shows that there was no significant difference in the levels of SR between male and female medical students. However, there was a significant difference between medical students having considerable psychiatric distress and those not having considerable psychiatric distress (F = 20.45, P < 0.001).
Table 15: Two-way ANOVA to analyze the effect of gender and psychiatric distress on seeking alternate rewards

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There was no significant difference in the levels of ED between male and female medical students. A significant difference in the levels of ED between medical students having considerable psychiatric distress and having no considerable psychiatric distress was observed. There was also significant interaction between the effects of gender and considerable psychiatric distress on ED (F = 5.272, P = 0.023) [Table 16].
Table 16: Two-way ANOVA to analyze the effect of gender and psychiatric distress on emotional discharge

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  Discussion Top


The main objective of the study was to find out the effect of psychiatric distress and gender on the levels of anxiety, depression, and suicidal ideation in medical students and also the coping responses utilized by medical students in the face of life stress. The study was also intended to find out the relationships among all these factors, that is, the relationship between state anxiety, trait anxiety, depression, suicidal ideation, and coping responses under different conditions.

In the case of psychiatric distress, 57.5% of males and 42.5% of females reported no considerable psychiatric distress, whereas 68.6% of males and 31.4% of females reported of having considerable levels of psychiatric distress. Overall, 54.8% of the participants (including both male and female) reported to have a considerable level of psychiatric distress. 88% of the participants exhibited above-average levels of state anxiety, although only 0.8% of them exhibited above-average levels of trait anxiety. 39.2% of the participants reported moderate-to-severe levels of depression and 27.6% of them reported frequent suicidal ideation, indicating the need for further suicidal screening.

In the case of coping responses, it was observed that majority of the participants utilize avoidance coping. Avoidance coping methods such as CA, AR, SR, and ED are frequently used medical students, as reported by this sample. Out of other avoidance coping techniques, ED was found to be the most frequently used coping response. This indicates that medical students are likely to resort to EDs in response to stressful situations and hence more likely to be vulnerable to emotional disturbances as well.

There was a significant difference in the levels of state anxiety, trait anxiety, depression, suicidal ideation, and coping responses between medical students having considerable psychiatric distress and medical students having no considerable psychiatric distress. There was no significant difference in the levels of state anxiety, trait anxiety, depression, suicidal ideation, and coping responses between males and females. There existed a significant difference in the levels of state anxiety, trait anxiety, depression, suicidal ideation, and coping responses among males below GHQ cutoff, females below GHQ cutoff, males above GHQ cutoff, and females above GHQ cutoff. Thus, it can be inferred that gender and psychiatric distress combined together have a significant impact on the levels of state anxiety, trait anxiety, depression, suicidal ideation, and coping responses in medical students.

Thus, it may be said that although gender independently has no significant impact on the levels of anxiety, depression, suicidal ideation, and coping responses in medical students, gender combined with psychiatric distress does have a significant impact on the above-mentioned dependent variables. Similar observations have also been observed in previous studies.[11],[13],[14]

Limitations

As far as psychological variables are concerned, only anxiety, depression, suicidal ideation, and coping have been addressed in this study. There are many other issues such as eating disorders, obsessive–compulsive disorders, substance addiction, nomophobia, and body dysmorphia that are nowadays raging the student population. These variables may be addressed in further researches.


  Conclusions Top


Majority of medical students experienced high amounts of state anxiety, despite having no history of trait anxiety or anxiety disorders. Psychiatric distress has a significant impact on the levels of depression, anxiety, suicidal ideation, and coping responses in medical students. Gender, on the other hand, plays no major role in the levels of anxiety or depression but plays a significant role in the case of suicidal ideation and ED in medical students, specifically those medical students who are already undergoing considerable levels of psychiatric distress. However, gender and psychiatric distress combined together have a significant impact on the levels of depression, anxiety, suicidal ideation, and coping responses in medical students. As far as the interrelationships among all the variables studied here are concerned, there is a significant relationship between state anxiety, trait anxiety, depression, suicidal ideation, and coping responses. Avoidance coping or emotion-focused coping is more in use among medical students as compared to approach coping or problem-focused coping, with ED being the most frequently used coping response.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13], [Table 14], [Table 15], [Table 16]



 

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