12 Int J Res Med. 2014; 3(4);12-20 e ISSN:2320-2742 p ISSN: 2320-2734
A Study of Stress Awareness among First Year Medical Students
Lata Gupta1*,Dharmendra Dodiya2, Vanita Panchal3, Beena Goyal4, Gunjan Movaliya5, Pranav Chakravarty6
1
M.D. Associate Professor, 2,3M.D. Assistant Professor, 4,5MBBS, Tutor, 6M.D. Professor & H.O.D, Department of Physiology, G.M.E.R.S. Medical College, Sola, Ahmedabad
INTRODUCTION
Stress is a term that refers to the sum of the physical, mental, and emotional strains or tensions on a person. Feelings of stress in humans result from interactions between persons and their environment that are perceived as straining or exceeding their adaptive capacities and threatening their well-being. The element of perception indicated that human stress responses reflect differences in personality as well as differences in physical strength or health.
A model dividing stress into eustress and distress. Where stress enhances function (physical or mental, such as through strength
*Corresponding Author Dr. Lata Gupta,
A – 61, Jupiter Towers, B/H Grand Bhagwati Hotel, Bodakdev, S.G. Highway, Ahmedabad –380054
Email: dr_lata@rediffmail.com Phon no: 079 26857268
Mo. No: 0091 9898329339
Training or challenging work) it may be considered eustress. Persistent stress that is not resolved through coping or adaptation, deemed distress, may lead to escape (anxiety) or withdrawal (depression) behavior. The difference between experiences which result in eustress or distress is determined by the disparity between an experience (real or
imagined), personal expectations, and
resources to cope with the stress1.
Stress is also closely associated with depression and can worsen the symptoms of most other disorders. Cumulative adverse experiences, including negative life events and early childhood adversity, together with parental depression and/or non-supportive school of familial environments, place young people at risk for developing depression. Enhanced life skills and supportive school and family environments can mediate the effect of stressful life events2,3.
According to WHO's Global burden of disease 2001, 33% of the years lived with disability (YLD) are due to neuropsychiatry disorders in which depression is one of four
ORIGINAL ARTICLE
ABSTRACT
BACKGROUND: Medical students are more distressed than the general population, especially in freshmen that face transitional nature of medical education life. A moderate degree of stress can promote student creativity and achievement, the intense pressures and relentless demands of medical education may impair students' behavior, diminish learning, destroy personal relationships, and ultimately, affect patient care. Objective: To assess the prevalence of depression by using the Center for Epidemiologic studies depression scale (CES-D) & to determine the sources of stress. Study will also find out the relationship between the main sources of stress, the general characteristics, potential personal consequences and depression among the first year Medical students. MATERIAL AND METHODS: In cross-sectional descriptive study design, CES-D being used to measure depression with cut-off point 22 and Students Stress Survey questionnaireincludes interpersonal, intrapersonal, academic & environmental factors were used as self-administrated to 145 first year Medical students of GMERS Medical College, Sola, Ahmedabad. Chi-squared test, Spearman correlation were analyzed in bivariate analysis to establish relationship between depression & student stress sources. RESULTS: The prevalence of depression was 22.07%. Stress scores and depression scores had positive linear relationship with r = 0.1912. Working with un-acquainted people, decline in personal healthand increased class workload as stressors were differentiated significantly with depressive group. Among those variables, quality of relationship, and stressors as decline in personal health, fight with friend increased the risk to get depression; in contrast, living with family, practice exercise and keep friendship reduced the risk of depression with p-value<0.05 in multivariate analysis. CONCLUSION: The students are facing social, emotional, physical, and family problems which affect their learning ability and academic performance which is evident in depressive symptom group of this study. For further study, qualitative and quantitative as longitudinal study should be conducted to determine consequences of daily hassles, level of stress and its relationship with depression in duration of Medical learning in India.
13 Int J Res Med. 2014; 3(4);12-20 e ISSN:2320-2742 p ISSN: 2320-2734
neuropsychiatry disorders of the six leading to causes of years lived with disability. More than 150 million persons suffer from depression at any point in time4.
Depression is a common mental disorder that presents with depressed mood, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy, and poor concentration. These problems can become chronic or recurrent and lead to substantial impairments in an individual's ability to take care of his or her everyday responsibilities5.
Conceptual frame work of study
The outcome variable is prevalence of
depression that related to general
characteristics, potential personal consequences and student stress. General characteristics include age, gender, living status, perception of financial status and coping with problems. The potential personal consequences consist of parent’s marital status, quality of relationship, and leisure/exercise activity. These factors change differently and influence on prevalence depression in medical students.
Figure: 1 Conceptual Framework
Independent Variable Dependent Variable
MATERIAL AND METHODS
This is a cross-sectional descriptive study that is used to measure the prevalence of depression, stress and related factors among the first year Medical students. This study had been conducted at GMERS Medical College, Sola, Ahmedabad on145 out of 150 1st year MBBS Students. All repeat students were sort out from this study population & excluded from this study.
Data collection methods were self – administrated. The questionnaire’s consisted of 3 parts with 74 questions, the first part were 14 questions about general information, the second part were depression measurement
in 20 items of the CES-D questionnaire, and the third were 40 questions about Student stress. Data were collected in classrooms with the prior approval for study by the Honorable Chairman, Research Committee, GMERS Medical College, Sola, Ahmadabad. Written consent information was explained to students before delivering questionnaire. It was informed to students that they can refuse to join this study without any effects on their study's result and no need to explain the reason. It was also informed to students that data collected will be used for research purpose only & their information will be kept confidential.
The content and face validity was checked by research team after constructing the draft questionnaire. The reliability test was done in pretest on 15 first year students in other Medical college of the city. Cronbach's alpha coefficients were used to measure reliability& internal consistency of the CES-D questions of pilot test. Cronbach's alpha coefficient for CES-D = 0.7148 were calculated& that is acceptable to take this study forward.
CES-D Questionnaire
This study adopted the Center for
Epidemiologic Studies Depression Scales (CES-D) to measure the levels of depression. The CES-D was designed to cover the major symptoms of depression It has been extensively used in large studies and norms are available. It is applicable across age and general groups. It has often been used in cross-cultural research6,7.
After collection of questionnaire duly filled by students, they were coded before entering the data to computer by the researcher. The sample database was checked by double entry. Data analysis was done by using ON LINE "Social Science Statistics Calculator" on http://www.socscistatistics.com/. The analysis part composed 2 parts, descriptive and analytical statistic. In analytical statistic, data were tested in bivariate analysis. Descriptive statistics such as frequency, percentage, mean, and standard deviation was applied for general characteristics, prevalence depression, sources of medical stress description.
In Bivariate analysis, Chi-square test and Fisher’s Exact test were used to test the relationship between depression and the students stress sources, and also for relationship between depression and living
General Characteristics 1. Age
2. Gender 3. Living Status 4. Perception of financial
status
5. Coping with problem
Potential personal consequences
6. Parent’s marital status 7. Quality of Relationship 8. Leisure/Exercise activity
Student Stress 9. Interpersonal Factors 10. Intrapersonal Factors 11. Academic Factors 12. Environment Factors
14 Int J Res Med. 2014; 3(4);12-20 e ISSN:2320-2742 p ISSN: 2320-2734
condition, perception of financial status, parent's marital status, and exercise/leisure activity, coping with problems, quality of friendship.
Non-parametric Spearman correlation was used to find association between 2 continuous variables: depression and age; also between depression scores and total stress scores. Testing of the hypothesis will be performed at 10% level of significances.
For depression variable, question scores were summed to provide an overall score ranging from 0 to 60. Four positive questions 4, 8, 12 and 16 were reversed by subtracting the score from 3. If more than 5 items on the scale are missing, a score is generally not calculated. If one to five items on the scale were missing, Score = Sum X 20 / No. of Questions Answered
Depression score was categorized by cut-off point into 2 groups below:
Scores less than 22 = Non- depressive symptoms group
Scores are 22 or more = Depressive symptoms group
About students stress sources including 40 questions, in non- parametric spearman correlation, students stress scores were summed up as a continuous variable with non normality distribution. In chi-square test, then, students stress was used separately in each 40 sources to find relationship with depression.
RESULT
This descriptive cross-sectional study was conducted in GMERS Medical College, Sola, and Ahmadabad. The study determined the prevalence of depression, sources of stress and factors related to depression among 150 first year Medical students. Total study populations were 145 students with 96.7% of response rate. The results are presented in four parts as follows:
1. General characteristics including general and potential personal consequence factors. 2. Prevalence of depression among the first
year Medical students.
3. Sources of stress among the first year Medical students.
4. Relationship between general characteristics, potential personal consequence factors, sources of stress and depression.
Description of General characteristics
There were 145 first year Medical students
that consisted of male more than female (59.3% v/s 40.7%).The student’s age ranged from 18 to 20 years, with a mean age of 18.61 and standard deviation of 0.58.The students lived with their friend (55.9%), their relative & family (36.6%), stay alone (7.6%).Most of the students were fully supported by their family with 95.2% students by parents, 1.4% students by sister/bother and 2.1% by their relatives. Others (1.4%) were supported by educational loan or sponsored by some institutions. Among the students, some of them had part-time job with 0.7%, the
remaining (99.3%) had no part-time
job.24.1% of students felt their finance status was nearly sufficient, 65.5% felt that it was sufficient and 8.3% answered that it was not enough for fee / living. 2.1% of the students said that their finance was very comfortable. When facing the problems, 37.1% of students talked with their friend, 39.6% talked to parents, 21.7% of them prayed, and others chose traveling, solving by themselves with 1.6%.
Potential personal consequence factors concluded quality of relationship with friends and with parents, parents' marital status, leisure, and exercise activities variables. 1. Satisfaction with friendship :10.3% of
students did not have close friend and only 6.9% had lover. Regarding satisfaction of relationship with friends, 46.9% satisfied, 49% very satisfied, 1.4% of student did not satisfy, only nearly 2.8% did not satisfy with their friend at all.
2. Parent’s marital status :Almost parents of students lived together (95.2%), remaining percentages with 3.4% of students lost their father or mother and 1.4% for separated parent.
a. Quality of relationship with parent’s :About the satisfaction of relationship with parents, the percentage of students very satisfied more than percentage of satisfied (88.3% vs 11.7%).
15 Int J Res Med. 2014; 3(4);12-20 e ISSN:2320-2742 p ISSN: 2320-2734
4. Exercise practice :The highest percentage did it Sometimes (≥ 1 Times & ≤ 3 Times/Month) by 60.7%; 7.6% of them did exercise seldom (< 1 Times/Month), 15.9% of students answered never doing. Doing exercise often (> 3 Times &< 12 Times/month) was responded by 8.3% and only 7.6% for practice always (12 times/month).
Student stress factor’s
Generally, students responded whole 40 items of student stress factors that focused on four main sources, including interpersonal, intrapersonal, academic & environmental sources. Students were asked about their experiences those events during this academic year (from 01 Sept. 2013 to 31 March 2014). The top 5 stress factors under each source are mentioned in table 1:
Table: 1 Top five Student Stress Factors Student stress Factors
(n=145)
Frequency %
Interpersonal Sources Trouble in Finding new Friends
Change is Social Activity Working with unacquainted people
Roommate Conflict Fight With Friend
139
108 85
43 38
95.9%
74.5% 58.6%
29.7% 26.2% Interpersonal Sources
Started Collage New Responsibilities Change in Sleeping habits Change in Eating habits Problem in Spoke in public
140 134 115 106 89
96.6% 92.4% 79.3% 73.1% 91.4% Academic Sources
Increased Class work load Expectation after graduation Lower Grade than anticipated Change of major
Missed to Many Classes
126 118 85 41 34
86.6% 81.4% 85.6% 28.3% 23.4% Environmental Sources
Vacation / Breaks Change in living environment Waited in long lines Placed in unfamiliar situations
Waiting for something for uncertainty time
121 102 84 71
58
83.4% 70.3% 57.9% 49.0%
40.0%
Prevalence of depression
Using CES-D question for asking the feeling or behaviors that the responder had during the academic year. Twenty scale questions scored from 0 to 3 as 0 for never or rarely, 1 for sometime, 2 for occasionally, 3 for mostly level were summed up of 20 questions. The minimum score and maximum was 3 and 36,
so the range was 3 - 36. The mean and standard deviation was 17.7 and 6. On analysis of data it was observed that out of total sample size of 145, total 32 students (22.1%) have depressive symptoms & 113 students (77.9%) does not have depressive symptoms. In depressive symptom group 18 students were male & 14 students were female students with mean age of 18.66 Years &standard deviation of 0.60.
Bivariate analysis: Relationship between depression and general characteristics
In statistical analysis by using Chi Square test, it is observed that relationship between depression & general characteristics like age, gender, whom students lived with, perception of financial status & ability to coping with problem were not having statistically significant differences at P – Value > 0.10. Relationship between depression and potential personal consequence
Potential personal consequence factors were satisfaction of relationship with their friends in general and parents. Satisfaction was a scale variable with 4 values as very satisfy, satisfy, not satisfy and not satisfy at all, but in Chi-square test 2 last values (not satisfy and not satisfy at all) was combined to become one value that was showed in table 2.
Quality of relationship with parents :There were not significantly difference between depression and quality of relationship with parents with at P-value = 0.877.
Exercise practice :There were not significantly difference between depression and exercise practice of students with at P-value = 0.819.
Leisure activities : Leisure activities including going out with friends, listening to music/reading book/watching TV/playing games, playing sports, sleeping, and others were checked separately the relationship with depression. Within each separate choice, there were no significantly differences in any relationship with P-value = 0.2711 Relationship between depression and student stress
16 Int J Res Med. 2014; 3(4);12-20 e ISSN:2320-2742 p ISSN: 2320-2734
0.0212.As Students stress survey approach, the student stress source focus on sources of stress so the relationship between depression and 40 student stress sources was characterized below: Interpersonal stress sources
In table 3, among 6 factors in interpersonal sources, only relationship between depression
and trouble with parent, finding new friend’s were statistically significant with P-value < 0.10. The 4 remaining sources that consisting working with un-acquainted people, roommate conflict, change in social activities and fight with friend were statistically not significant.
Table: 2 Relationship between Depression & Quality of friendship
Depression X Value P- Value (P at 0.10)
Remark Non Depressive
Symptoms
Depressive Symptoms (n) % (n) % Relationship with friend (n = 145)
Satisfy 13 46.4% 15 53.6% 41.7839 0.00001 Very Highly
Significant
Very Satisfy 99 89.2% 12 10.8%
Not Satisfy + Not Satisfy at all 0 0.0% 5 100%
Relationship with friend- having no close friend (n = 15)
Satisfy + Very Satisfy 11 100% 0 0% **Fisher’s
Exact test
0.0007 Highly
Significant
Not Satisfy + Not Satisfy at all 0 0 4 100%
Having Lover (Boy / Girl friends) (n = 145)
Yes 5 50% 5 50% 4.8721 0.02729 Significant
No 108 80% 27 20%
Table: 3 Relationship between Depression & Interpersonal Sources
Depression X Value P- Value (P at 0.10)
Remark Non Depress
(n) % (n) % Interpersonal Sources
Finding new friends Yes No
109 4
80% 50%
28 4
20% 50%
3.84 0.05 Statistically
Significant
Trouble with Parents Yes No
5 108
50% 80%
5 27
50% 20%
4.872 0.02729 Statistically
Significant
Table: 4 Relationships between Depression & Interpersonal Sources
Depression X Value P- Value (P at 0.10)
Remark Non Depress
(n) % (n) % Interpersonal Sources
Change in Sleeping habits Yes No
93 20
81% 67%
22 10
19% 33%
2.791 0.0948 Statistically
Significant
Problem in Spoke in Public Yes No
74 39
83% 70%
15 17
17% 30%
3.644 0.0563 Statistically
Significant
Intrapersonal stress sources
In table 4, among 16 intrapersonal sources, there were only 2 sources as change in sleeping habits and problem in public speaking had
significantly differences. Other 14
intrapersonal sources like started college, new responsibilities, change in eating habits, outstanding personnel achievements, decline in personnel health, financial difficulties, change in religious beliefs, minor law violation, death of a family member, sever injury, held a job, death of a friend, engagement / marriage, change in alcohol / drug had no significantly differences.
Academic stress sources
According to table 5, in comparison between depression toward 8 academic stress sources, only increased workload, change in major and depression relationship had significantly differences, the 6 rest sources like expectation after graduation, lower grade than anticipated, missed too many classes, search for job, transferred school & serious arguments with instructor had no significant differences as P-value>0.10.
Environmental stress sources
17 Int J Res Med. 2014; 3(4);12-20 e ISSN:2320-2742 p ISSN: 2320-2734
stress factor and depression found that only 4 differences significant with P- values < 0.10, including change in living environment, messy living conditions, computer problem and divorce between the parents. Rest 6
factors vacation / breaks, waited in long lines, placed in unfamiliar conditions, waiting for something for uncertain time, vehicle trouble & quit job had no significant differences as P-value>0.10.
Table: 5 Relationships between Depression & Academic Sources
Depression X Value P- Value (P at 0.10)
Remark Non Depress
(n) % (n) % Academic Sources
Increased Class work load Yes No
95 18
75% 95%
31 1
25% 5%
3.591 0.058 Statistically Significant
Change of major
Yes No
28 85
68% 82%
13 19
32% 18%
3.088 0.07888 Statistically Significant
Table: 5 Relationships between Depression & Environmental Sources
Depression X Value P- Value (P at 0.10)
Remark Non Depressi
(n) % (n) % Environmental Sources
Change in living Environmental Yes No
76 37
73% 90%
28 4
27% 10%
5.039 0.0248 Statistically
Significant
Messy living conditions
Yes No
19 94
63% 82%
11 21
37% 18%
4.687 0.0303 Statistically
Significant
Computer Problem
Yes No
12 101
60% 81%
8 24
40% 19%
4.337 0.0373 Statistically
Significant
Divorce between the parents Yes No
0 113
0% 79%
2 30
100% 21%
7.161 0.0075 Statistically
Significant
DISCUSSION
The first year students were the subject in the age of 18 year (64 Students) & 19 year (73 Students), some of them were 20 year old (8 Students). They had to face to the transition from a personal to an impersonal academic environment.Medical students, especially freshmen, were risk subjects of stress due to the transitional nature of life8,9,10.
Prevalence of depression among the first year Medical students was 22%. This finding was lower than the result in some previous studies11 of adolescents aging between 18 to 21 with 33.1%11,12.
In bivariate analysis, regarding gender, male students seem to be higher in prevalence of depressive symptom than female13. Being a first year student, female and male faced to similar changes in the transition stage of life and they also learnt in the same conditions in the medical life.
In previous study, gender differences existed in depressive symptoms in all subjects with
p-value < 0.001, female were more likely than males to have depressive symptoms12.Further 39.6% of the first year Medical students were having depressive symptom (> 22 scores), 60.4% of them had no depressive symptom11 (< 22 scores).
The depressed adolescents had less optimal peer relationships, fewer friends, less popular, less happiness, and more frequents suicidal
thoughts. They spent less time doing
homework, had a lower grade point average, and less time exercising14.
18 Int J Res Med. 2014; 3(4);12-20 e ISSN:2320-2742 p ISSN: 2320-2734
interpersonal skills can create difficulties for adolescents in changing relationship with peers15.
The General health questionnaire, 24 items to assess sources of stress showed that the most important and severe sources of stress were staying in hostel, high parental expectation, vastness of syllabus, test/exam, lack of time and facilities for entertainment16.
Our study resultsuggests that students never exposed to exercise practice have higher prevalence to depressive symptoms (30.4%) than students often exposed to exercise (16.7%). A study also found that exercise activity associated with a reduced odds of depressive symptoms17. The other study in high school senior differentiated in the depressed and non depressed group, showing depressed group was found to engage in less physical activity14. Experts recommend performing about 20 minutes of aerobic exercise three times a week. Stretching is a form of exercise that relieves muscle tension. A brisk walk is a healthy way to clear the mind and relieve tension.
In view of using leisure time effectively, going out with friend or listening to music/read book/TV/game or playing sport had positive meaning. Those students who chose more than 2 positive choices get less depressive symptom than the students had one leisure choice. A huge and broad information and knowledge in very specific major of Medical increase pressure of overload working for students, presenting in high prevalence of stress in
increased class workload (86.9%) and
expectations after graduation (81.4%). This result was in consistency with a previous study18. In addition, 79.3% of students changed their sleeping habit, 73.1% of students changed their fooding habits & which might be a result from not only too many class works but also from lack of time management skills and learning strategy18,19.
Interpersonal stress factors raised from interaction with other people, such as friends, parents, etc was responded with highest percentage of stress caused by working with
unacquainted people (62.7%).The most
common sources of stress were interpersonal as "finding new friend" (76.2%), the intrapersonal sources as "new responsibilities (72.1%) and "started college (65.8%), that this factor and "change in sleeping habits" were significantly
greater stressors in first year students than in students of other years. The other prevalence was academic stressor as "increased class workload" (66.9%), environment sources as "being placed in unfamiliar situations" (64.2%), and "waiting long line", "change living environment" that were significantly greater in first year students. These finding consisted with stressors, intrapersonal sources were the most common source of stress3,20. Majority of medical students (175 of 283, app. 73%) perceived stress publishing by a study22 of stress in medical students by Zung's Self – Rating Scale. Academic factors were greater perceived case of stress in medical students.
Emotional factors were found to be
significantly more in first year students as compared to second & third students. Stressful life events was powerful predictor of depression in longitudinal study22.
There were significant associations between depression and general characteristics in bivariate analysis. Quality of relationship with friends have great deal of influence on depressive symptoms in students. Those students who were not having close friends (100%) have higher prevalence of depressive symptoms. They might be faced many difficulties in medical learning and adaptation many changes in culture of the city life as well. Satisfaction of relationship revealed the quality of relationship with parents and friends which were considered as very important support systems for students. There were highly significant difference between those potential
personal consequences and depression,
presenting with p-value < 0.01 for more satisfaction with friends less depressive symptom and p-value = 0.10 also for higher in dissatisfaction of relationship with parents
higher prevalence of depressive
symptomatology. There was consistency with other studies in finding of peer and parents relationship, which were associated with depressive symptom23.
The association between depression and stress was analyzed in Spearman Correlation for non parametric statistics test. Stress scores and
depression scores had positive linear
19 Int J Res Med. 2014; 3(4);12-20 e ISSN:2320-2742 p ISSN: 2320-2734
messy living conditions, computer problem and divorce between the parentswere differentiated significantly with depressive group& these were the stress factors who had been found statistically significant with respect to depression of depressive symptom group. The resultrevealed that the support system from parents and friends was very important. Good relationship reduced depression and versus poor relationship leaded to more troubles, stress and depressive symptoms.
The most commonly used coping strategies are going along with parent, praying, making one's own decisions, apologizing, helping other people to solve problems, keeping friendships and daydreaming.
CONCLUSION
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 integrating into the system. The students also face social, emotional, physical, and family problems which may affect their learning ability and academic performance.
Prevalence of depressive symptom among first year Medical students was high with 22.1% by using the CES-D tool for screening depression with cut-off point ≥ 22.
It is suggested that longitudinal study should be carried out to determine consequences of daily hassles and life events that related to depression during students' learning time stages.
Maintaining and enhancing support systems from friends& families should be promoted for students in coping with problems in learning and life skills as well through supporting from seniors, exercise and sports should be encourage to practice regularly combining with extra activities in medical college.
REFERENCES
1. Lazarus RS. In:Psychological stress to the emotions: a history of changing outlooks. Annual Review of Psychology. 1993; 44, 1-22.
2. Dahlin M, Joneborg N, Runeson B. Stress and depression among medical students: a cross-sectional study. Medical Education. 2005; 39(6), 594-604.
3. Seyedfatemi N, Tafreshi M, Hagani H. Experienced stressors and coping strategies among Iranian nursing students. BMC Nursing. 2007; 6, 11.
4. World Health Organization [WHO].
Investing in mental health. Geneva: Nove Impression, Switzerland. 2003.
5. World Health Organization [WHO].
Depression. Retrieved April 15, 2014, from http://www.who.int/topics/depression/en/. 2008.
6. McDowell I. Measuring Health, A guide to rating scales and questionnaires (3nd ed.). New York: Oxford University press.2006. 7. Iwata N, &Buka S. Race/ethnicity and
depressive symptoms: a cross-
cultural/ethnic comparison among
university students in East Asia. North and South America. Social Science & Medicine. 2002; 55(12): 2243-2252
8. Aktekin M, Karaman T, Yesim Y, S, Erdem S, Erengin H, &Akaydin M. Anxiety, depression and stressful life
events among medical students: a
prospective study in Antalya,
Turkey.Medical Education. 2001; 35(1): 12-17
9. Dahlin M. Future doctor: Mental distress during medical education: cross-sectional
and longitudinal studies. Doctoral
dissertation, Clinical Neroscience, Division of psychiatrySt.Goran, Karilinska Institute. 2007.
10.Morrison J, Moffat K. More on medical student stress. Medical Education. 2001; 35(7): 617-618.
11.Somrongthong R. Adolescent health needs, Accessibility of services, Depression and Quality of Life by assisting in the development of community partnerships. Doctoral dissertation, College of Public Health, Chulalongkorn University. 2004. 12.Yuqing S, Yueqin H, Liu D, Kwan JSH,
Fuquan Z, Sham, PC, et al. Depression in
college: depressive symptoms and
personality factors in Beijing and Hong Kong college freshmen. Comprehensive Psychiatry. 2008
13.Cho MJ, Nam JJ, Suh GH. Prevalence of symptoms of depression in a nationwide sampel of Korean adults. Psychiatry research. 1998; 81(3): 341-352.
14.Field T, Diego M., & Sander C. Adolescent depression and risk factors. Adolescence. 2001; 36(143): 491-498.
20 Int J Res Med. 2014; 3(4);12-20 e ISSN:2320-2742 p ISSN: 2320-2734
and can we prevent it? The Medical Journal of Austral i a. 2002; 177: 93-96.
16.Screeramareddy CT, Shankar PR, Binu V, &Menezes RG. Psychological morbidity, sources of stress and coping strategies among undergraduate medical students of Nepal. BMC Medical Education. 2007; 7: 26.
17.Wise LA, Adams-Campbell LL, Palme JR,
Rosenberg L. Leisure time physical activity in relation to depressive symptoms in the Black women's health study. Ann Behav Med. 2006; 32(1): 68-76.
18.Shields N. Stress, active coping, and academic performance among persisting and non persisting college students. Journal of Applied bio behavioral research. 2001; 6(2): 65-81.
19.Misra R, McKean M. College students academic stress and its relation to their anxiety, time management, and leisure
satisfaction. American Journal of Health Studies. 2000; 16(1): 41-51.
20.Ross SE, Niebling BC, Hecker, TM. Sources of stress among college students. College student Journal. 1999; 33: 312-314. 21.Supe A. A study of stress in medical students at Seth G.S. Medical College. Journal of Postgraduate Medicine. 1998; 44(1): 1-6.
22.David AC, Nolen-Hoeksema S. Stress exposure and stress generation in child and adolescent depression: A Latent trait-state-error approach to longitudinal analyses. Journal of Abnormal Psychology. 2006; 115(1): 40-51.
