Psychological Morbidities and Coping Styles: A Rural Institution-Based Cross-Sectional Comparative Study between Undergraduate Medical Students Undergoing Different Phases of Training

Introduction

The study of medicine including vigorous training schedule is distinctive and more mentally challenging than any other professional courses worldwide.¹ Undoubtedly, this unique curriculum in itself is highly stressful,² and jeopardizes the emotional and mental well-being of students, who develop burnouts throughout the study courses.^3,4 Previous literature has confirmed that poor mental health was a predictor of a cascade of psychological morbidities such as depression, anxiety, suicidal behavior, and substance abuse.^5,6,7,8 A recent survey in India⁹ revealed that 60.3% of medical students had psychological morbidities, which was much higher than other studies conducted in the past.^10,11,12 This growing evidence of untreated psychological morbidities in medical students is attributed to barriers in seeking psychiatric consultation, which has been a prime concern for mental health authorities.¹³ A nationwide survey in Brazil¹⁴ showed a higher prevalence of psychological problems among first-year medical students as compared with the final-year students, while other authors have reported a notable rise in prevalence with progressing years of study.^1,15,16,17

The transition from a theoretical framework to a clinical phase has been identified as a crucial stage in medical training, regarding students' stress.¹⁸ Students in clinical training were distinct from pre-/para-clinical undergraduate (UG) students in many ways, and thus are likely to encounter different stressors. The most obvious difference is that all clinical UGs in addition to examination stress also have intense emotional experiences while interacting with dying patients, interpersonal problems with patients, and work overload,^19,20 while pre-/para-clinical UGs who tend to be school-passouts or, at most, have taken a “gap year” face a transitional environment of professional college life, which compels them to acquire new skills for peer-competition and difficulties envisaged for integration into the system, separation from family, unlimited parental expectations, and academic stress.^21,22 Existing findings in the literature concerning the relationship between psychological morbidities and phase of study are still controversial.^20,23,24

At the same time, stress drives medical students to develop certain cognitive skills and behavioral strategies to reduce or tolerate the stressful situations.²⁵ Few studies consistently demonstrated that active coping styles could generate problem-solving behavior and emotion regulations,²⁶ while passive coping skills focused on emotion expression, negative appraisal, and social isolation could enhance the risk of psychological morbidities while confronting stressful situations.^27,28 It was noted that self-blame and denial were used mainly by first-year medical students while later year students shifted toward cognitive, confronting, and planned problem-solving strategies.²² In addition to having different and perhaps more severe stressors, given their maturity and greater life experiences, UGs in clinical years are likely to use different coping styles compared with their counterparts but how their respective coping behavior might also differ remains relatively unclear.

There has been extensive research on psychological morbidities, associated factors, and coping styles, and their relationship with year of study in medical students^{9,10,14,15,16} but the literature is inconsistent in Indian medical students,⁵ which evaluated and compared the psychological morbidities and coping styles in pre-/para-clinical and clinical group of UGs. These assessments become imperative prior to designing and implementing the interventions to preserve their mental health and reduce psychological morbidities. Therefore, the present study sought to assess and compare the magnitude of psychological morbidities, factors associated with it and the coping styles between pre-/para-clinical and clinical UGs in an institution located in a rural area of northern India. This study also evaluated and compared the association between psychological morbidities and predictors among both the study groups.

Materials and Methods

Sample Size

The study's required sample size (N = 382) was calculated by using a single population proportion formula. It was calculated on the basis of the following assumptions: nearly 50% of the students would have psychiatric morbidities (P) and the absolute precision is 5% (d) at 95% confidence interval (CI; Z).

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Results

Three hundred and eighty-two medical students were enrolled in the present study. The majority of participants were female (62%; n = 239) and the mean age of the sample was 20.40 (SD = 1.85) years with a range of 18 to 26 years. As expected, the mean age of the clinical group (21.90 years; SD: 1.58) was significantly (p < 0.001) higher as compared with that of the pre-/para-clinical group (19.15 years; SD: 0.87). Most of the respondents in both the study groups were members of nuclear families and coming from rural areas. Around 90% of the students were staying in hostel premises. Further, majority of the students (60%) used to sleep for more than 6 hours per day on an average and did not participate in any physical exercise for ≥3 days/week. Around 29% of the respondents were at that time consuming one or more substance, with a statistically significant higher proportion in the clinical group than the other group of students (38.5 vs. 20.2; p < 0.001) (►Table 1).

The distribution of responses to the items of academic and personal characteristics of students, shown in ►Table 2, demonstrated that most of the respondents were dissatisfied with their academic performances, while only 12 to 19% of the students cited that they were at that time on psychiatric treatment, sought psychiatric consultation, studying medicine under family pressure, or had family history of psychiatric illness. When the differences between the two groups were evaluated, students in the clinical years had a statistically significant higher proportion with dissatisfied academic performance (72.4 vs. 52.8; p < 0.001), had sought psychiatric consultation during a semester (20.1 vs. 9.6; p = 0.004), and were on psychiatric treatment (16.1 vs. 9.1; p = 0.04).

Adjusted Binary Logistic Regression Analysis of Psychological Morbidities in Pre-/Para-clinical and Clinical Groups

The results of cross-sectional association between independent variables and psychological morbidities in both study groups are shown in ►Figs. 1 and 2, which depict sole significant predictors of psychological morbidities. The participants in both the study groups who reported dissatisfaction with academic performance, average sleeping <6 hours per day, and doing physical exercises <3 days/week were found to be more likely to have psychological morbidities. In the clinical years, those students who consumed substances like tobacco, alcohol, opioid, etc. were found to be more likely to have psychological morbidities (p = 0.016) when compared with those who did not consume.

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Fig. 1

Forest plot showing binary logistic regression analysis of psychological morbidities in pre-/para-clinical medical students. **p < 0.01; ***p < 0.001. aOR, adjusted odds ratio; odd ratio adjusted for current age, gender, residence (born/raised before entering the course), type of family, and living status during the course; CI, confidence interval.

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Fig. 2

Forest plot showing binary logistic regression analysis of psychological morbidities in clinical medical students. *p < 0.05; **p < 0.01; ***p < 0.001. aOR, adjusted odd ratio; odds ratio adjusted for current age, gender, residence (born/raised before entering the course), type of family, and living status during the course; CI, confidence interval.

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Discussion

Medical training-related psychological morbidities are a widely known phenomenon, and go conjointly with complexity, obscurity, and challenges of the profession. Keeping this in mind, the present research was conducted using semi-structured instruments to assess and compare psychological morbidities, and their possible association with predictor variables and coping styles. The present study revealed that a staggering 61% of medical students had an abnormal score (>23) on GHQ-28, which is suggestive of higher prevalence of psychological morbidities. Several previous studies from India and other parts of the world^9,32,33 lend support to the findings of the present survey and demonstrated a similar higher prevalence of psychological morbidities by using the GHQ-28 scale among medical students. This might suggest a decrease in the psychological health of medical students when one compares the findings of the present study with the studies conducted previously in different areas of the world which evaluated a lower prevalence of psychological morbidities.^{5,10,21,34,35,36,37} Also, the prevalence of psychological morbidities in the present survey was much higher than the global prevalence estimated by a meta-analysis of medical students in Asia⁶ and Nigeria.³⁸ These discrepancies might be related to differences in socio-cultural background, sample size, and study design used. The high prevalence of psychological morbidities might be due to significantly higher workload related to academics which leads to burnouts among study participants.

In the present survey, the prevalence of psychological morbidities among pre-/para-clinical and clinical UGs was found to be 60.6 and 61.5%, respectively, but any statistically significant difference in GHQ-28 scores could not be found, suggesting that the rate of psychological morbidities is almost equal in both study groups. This result is in contrast to the findings of a study done by Beniwal et al⁵ and Konjengbam et al,³⁹ in which the authors as per GHQ-60 and GHQ-12 scales, respectively, observed that the proportion of psychological morbidities among pre-/para-clinical UGs was higher than that of clinical UGs, which was found to be statistically significant. Currently not much data are available within the existing literature for the comparison of psychological morbidities among both the study groups because in most of the previous surveys,^14,15,16 the psychological problems faced by the medical students were compared on the basis of their year/semester of study, and also, the other available literature^20,23,24,40 compared the psychological distress (using PSS-10 [Perceived Stress Scale] and GHQ-12) rather than psychological morbidities among pre-/para-clinical and clinical UG groups. This finding in the present study might suggest that students have certain common factors related to psychological morbidities but the training-phase factor plays a small role. The slightly higher preponderance of psychological morbidities toward clinical group of UGs is understandable, considering the fact that they are under constant pressure of academics and insecurities about not attaining their goal of being a physician.^19,26

The observation of the present survey demonstrated that socio-demographic variables such as age and substance consumption behavior were statistically significant between the comparable groups with psychological morbidities. These results were nearly similar to the observations of few studies done by Mangalesh et al⁹ and Biswas et al³⁵ in which psychological morbidities among different years of UGs training were statistically significantly associated with age, gender, living status, and substance consumption behavior. Zvauya et al²¹ and Kiran et al³² also found that psychological morbidities among pre-/para-clinical and clinical UGs were statistically significantly associated with age of the participants. In assonance with the present survey, studies from India³² and another developed country¹⁵ had also suggested that with advancement of age and phase of training, the increased academic load and responsibility bestowed upon them engendered stress and made them highly susceptible to psychological morbidities. On the contrary, the cross-sectional survey by Beniwal et al⁵ pointed out that socio-demographic factors were nonsignificant between the comparable groups with psychological morbidities. Recently, a few authors from India^9,35 established a significant association where substance consumption behavior increases five to 10 times odds risk of psychological morbidities among medical educators. The present study also investigated that the substance consumption behavior among clinical UGs significantly increased the propensity of psychological morbidities, having approximately five times higher odds, though it cannot be said for the pre-/para-clinical UGs as the association between psychological morbidities and substance consumption behavior was not statistically significant despite having higher odds (1.25 times). This finding might support the results of other surveys^9,41 where it was hypothesized that students in clinical years adopted these detrimental habits in response to their struggles and personal grievances, and need a special mention because of the deteriorating effects on the cognitive functions. Taneja et al⁴² observed that univariate analysis did not confirm the evidence regarding the significant association between psychological morbidities and substance consumption behavior in medical students, inconsistent with the findings of the present survey.

In the present study, the results yield a significant effect of dissatisfaction of academic performance on the prevalence of psychological morbidities among medical UGs (both groups). These findings align with previous research in the literature which reported that dissatisfaction with academic performance was one of the key factors in inducing the mental health issues among medical students.^9,35,43,44 In the present survey, it was also highlighted that students in the clinical group were more in proportion with dissatisfied academic performance than the pre-/para-clinical group, validating the already existing findings where dissatisfaction with academic performance proportionally increased with advancement in phase training.¹⁵ This could possibly be due to self-perceived lack of knowledge in clinics, and insecurities about clinical competencies and future careers, leading to fear of failure in exam, due to which students might have feelings of worthlessness, hopelessness, and uselessness that ultimately lead to multiple mental health issues. The holistic learning approaches like self-directed learning, acquisition of mentoring support, and reduced stakes on assessment through new medical curriculum might prove promising in alleviating these stresses and associated psychological morbidities in medical UGs.

Previously, it was well established that multiple factors such as stigmatization, denial of mental health problems, informal consultations, concerns about confidentiality, fear of unwanted interventions, and self-diagnosis among medical students were the key influencers on the decision-making process of the student's psychiatric help-seeking behavior.⁴⁵ The present study suggested that more than three-fourths of students with psychological morbidities are still suffering in silence and notoriously reluctant to seek psychiatric consultation. This finding on the rate of seeking of psychiatric consultation among medical students with psychological morbidities is in the range of previous meta-analysis¹⁷ and a study conducted on American surgeons.⁴⁶ Previously, it was formulated that students in later phases of training got correct knowledge regarding the etiology of psychological problems and psychiatric medicine, which was significantly related to student's disposition to use psychiatric services,⁴⁷ similar to the results of the present survey where a significant proportion of students in clinical years sought psychiatric help and are currently on psychopharmacotherapies. Accordingly, it can be said that there is a need to initiate psychoeducation program for the medical students at the initial stages of training where “naturalization” of symptoms contributes to nonrecognition of the psychological problems.

The present study is among the firsts to assess how a subset of medical students copes in response to psychological morbidities and how their phase of training affects those coping behaviors. As mentioned in the present study, coping styles adopted by medical students were found to be average among a large number of participants, which was in line with this notion among medical UG students in a midwestern university.⁴ Indeed, there is a growing body of evidence supporting that the further medical students get in their education, the more emotionally taxing it might be.^48,49 This pattern in medical education literature aligns with the observations of the present study where emotional coping styles were used relatively more commonly by the clinical students as compared with another group, while findings revealed by Bamuhair et al²² were inconsistent with this notion. However, a significant positive correlation between psychological morbidities and PEC and PPC scores in clinical years indicates that coping styles adopted by students at a very challenging stage of medical education were not satisfactory and predicts stress in long term. These findings align with reports in the other parts of the world, showing that medical students in later versus earlier years of training tend to use more passive coping strategies, which tend to emanate when stressors are perceived as uncontrollable.^50,51 Also, this result is in contrast with few cross-sectional studies done in India⁵¹ and United States⁵² which showed that active-problem coping style was significantly higher in early years of training than in the later years. Hence, how students cope likely depends on the unique environments and stressors they face in each phase of their training.

The main strength of the present study is that this study is, to our awareness, the first to evaluate and compare the psychological morbidities and coping styles in pre-/para-clinical and clinical groups of UGs. Next, the study also helped in finding the vulnerable groups of medical students and phase of medical training by using standardized validated tools with very good internal reliability. Thus, the results observed were intriguing and had effective therapeutic implications in the prevention of psychological morbidities among medical students.

Findings of the present study must be interpreted in light of the limitations of this study. First, it is important to note the inherent limitations of self-reported measures as the rates of psychological morbidities reported in the present study were based on self-reported questionnaires and not on detailed psychiatric evaluations. Second, the present study did not evaluate the specific factors associated with the work-related stress. Third, the present survey performed a cross-sectional assessment which precluded definitive conclusions regarding the direction of causality. Future studies must follow longitudinal study designs to overcome this limitation of the study. Fourth, the study population consisted only of medical students in one institute and therefore may not be extended directly to other settings. Lastly, all the medical UG students were eligible to participate in the study and there were no exclusion criteria. This may lead to a self-selection bias, as medical students with psychological problems may be less motivated to complete the questionnaires, or on the other hand they may be more likely to participate since the topic is relevant to them.

Conclusion and Future Suggestions

The result of the present study reflected that a higher proportion of medical students experienced psychological morbidities. It was also suggested that psychological morbidities are significantly associated with substance consumption behavior and dissatisfaction with academic performance in clinical years. These findings implied that there is an urgent need to develop mechanisms to evaluate other factors associated with psychological morbidities and related targeted measures to decrease substantially the burden of psychological problems on the students. At the same time, there is a need to mitigate stigma associated with mental disorders so that at the time of the need, the students can seek psychiatric help. By broadening the use of psychiatric consultation and adopting more active and less passive coping skills, psychological problems may be prevented or at least diminished among medical students. Stress-reducing techniques and mentoring support need to be encouraged in curriculum, and counselors should be provided for effective addressing and solving the problems.