INTRODUCTION:

Medical education is quite competitive in the whole world. The long duration of the medical
education exposes medical students to serious mental health problems. The mental health
status of a medical student was comparative to the general population before the start of
medical training[1]. Depression and anxiety are among the most frequently occurring mental
disorders. Mental disorders have gained increasing attention of the whole world due to harmful
effect on working ability and the performance of people[2].
Medical students experience a unique collection of psychological and academic stressors as
they progress in their journey to become aspiring physicians[3]. Depression is characterized by
persistent and recurrent sadness or lack of pleasure that effects a person’s functional ability to
learn, work or do activities in daily life[4]. Both anxiety and depression can have a major effect
on performance, learning, eating and overall productivity of medical students[3]. A qualitative-
quantitative study conducted at a medical college from August 2016 to March 2017, when
asked about the reasons for psychological distress, the major issue identified by medical under
graduates was academic pressure[5]. There is evidence of a bi-directional relationship in
medical students between anxiety and academic performance[6].
The WHO reported that the prevalence of depression across the globe is currently 4.4%.
However, the prevalence of depression in medical students is reported to be 3–10 times higher
than the general population(11.5–48.2%)[4]. Depression is a prevalent mental condition,
affecting approximately 3.8 % of population across the globe, including around 5 % of adults in
the whole world[3]. In Pakistan, prevalence of anxiety (47.7%) among medical students was
quite high. 27.6%, 13.6% and 6.5% of the students were suffering from mild, moderate and
severe anxiety symptoms respectively. In India, a study suggested that round about 66.9% of
medical students were suffering from anxiety[7]. Among medical students, anxiety is prevalent
in 33.8 % , while depression and suicidal ideation affect 27.2 % and 11.1 %, respectively[3].
Furthermore, many studies showed that game addiction and internet have directly placed
influences on anxiety, stress, and depression in medical students. In addition, psychiatric issues
like anxiety, loneliness, and burnout have also correlated with depression positively in many
recent studies[4]. A study carried out among medical students showed a difference in
prevalence among male and female students with twice the rate of anxiety among females
compared to males (40% versus 20%)[7]. A study in Pakistan described that undergraduates
with history of depression and anxiety in family, students with drug addiction and students who
recently lose their loved ones were more at risk to suffer from psychological disorders and get
anxious easily than other students[7].
Undergraduate medical studies are more prone to stressful conditions as compared to other
undergraduate program[8]. In Pakistan, a few studies have been conducted on medical
students that showed they are affected more and prevalence of anxiety and depression is
high[8].Our study aimed to estimate the prevalence of depression and anxiety among medical
students in order to enhance our understanding of their mental health. Identifying these issues
could assist educational institutions in developing targeted interventions, ultimately mitigating
the negative effects of these disorders and fostering a healthier educational environment.

Methodology:
This was an exploratory, cross-sectional analytical study conducted for the assessment of
prevalence of depression and anxiety among medical students in Pakistan. Data were collected
through self-administered digital surveys using the nine-item Patient Health Questionnaire
(PHQ-9) for depression and the Generalized Anxiety Disorder (GAD-7) scale for anxiety. The
combined questionnaire comprising 17 questions was distributed through various social media
platforms.

Study Population:
The target population of this study consisted of medical students. All the medical students who
participated in the survey were included, without applying any specific exclusion criteria.
STROBE checklist guidelines were followed to ensure transparent reporting.

Sampling Technique And Sample Size:

A convenience sampling method was employed for this study. The survey was circulated widely
across various social media platforms to reach as many medical students as possible. Data was
collected from May 2024 to July 2024. A total of 206 responses were gathered during this data
collection period. Since all participants met the inclusion criteria, no responses were excluded
from the study.

Data Collection Tools:

Data on depression and anxiety were collected using the Patient Health Questionnaire (PHQ-9)
and Generalized Anxiety Disorder (GAD-7) scales, respectively [9,11]. A combined questionnaire
of 17 questions was provided in a digital format, allowing the participants to fill the
questionnaire on their electronic devices.

Scores of 0, 1, 2, and 3 were assigned to the response categories of “not at all,” “several days,”
“more than half the days,” and “nearly every day” respectively. GAD-7 total score for the seven
items ranges from 0 to 21 where grading was done as 1–4: minimal anxiety, 5–9: mild anxiety,
10–14: moderate anxiety, 15–21: severe anxiety [11]. PHQ-9 total score for the 9 items ranges
from 0 to 27 where grading was done as 1–4: minimal depression, 5–9: mild depression, 10-14:
moderate depression, 15–19: moderately severe depression, 19–27: severe depression[10].
In addition to these primary variables, sociodemographic information such as age, gender, and
year of study in medical university was also collected.

Data Analysis:
The collected data were analyzed using the Statistical Package For Social Sciences (SPSS) version
27.0 (IBM SPSS Corp. Armonk, NY, USA) to determine the prevalence of depression and anxiety
among the study population. All of the continuous variables were expressed in the form of
means and SDs, while categorical variables were expressed in the form proportions. To assess
any existing association between gender and prevalence of depression, a chi-square test was
applied at 5% level of significance.

RESULTS:
Of the 216 respondents, 55.6% (n=120/216) were females and 44.4% (n=96/216) were males.
29.6% (n=64) of them were from 1st year students, 20.4% (n=44) from 2nd year, 11.1%(n=24)
from 3rd year, 13%(n=28) from 4th year and 25.9%(n=56) were from final year MBBS.

TABLE 1:
Demographics;
Year of study: n(%) Gender: n(%)

1st Year 64(29.6) Male 96(44.4)

2nd Year 44(20. 4) Female 120(55.6

)

3rd Year 24(11.1) Total 216(100)

4th Year 28(13.0)

5th Year 56(25.9)

Overall, according to GAD-7 questionnaire 35.2% (n=76) of the respondents reportedly had
minimal anxiety, 28.7%(n=62) had mild anxiety, 12% (n=26) had moderate anxiety while 24.1%
(n=52) had severe anxiety over the past couple of weeks. These results are showed here in the
underlying table 2;

TABLE 2: Anxiety Table

n(%)

Minimal Anxiety 76(35.2)

Mild Anxiety 62(28.7)

Moderate Anxiety 26(12.0)

Severe Anxiety 52(24.1)

Total 216(100)
 AnxietyScoreIn
Minimal Anxiety
Mild Anxiety
Moderate Anxiety
Severe Anxiety

Table 3; Adaptation of Generalized Anxiety Disorder(GAD-7):

Questions: Not at all Several More Nearly

Over the last 2 weeks, how often have you been days than half everyday
bothered by any of the following problems? n(%) the time
n(%) n(%) n(%)

1. Feeling nervous, anxious, or on edge 66(30.6) 88(40.7) 34(15.7) 28(13.0)

2. Not being able to stop or control worrying 72(33.3) 60(27.8) 48(22.2) 36(16.7)

3. Worrying too much about different things 56(25.9) 62(28.7) 52(24.1) 46(21.3)

88(40.7) 50(23.1) 42(19.4) 36(16.7)

 4. Trouble relaxing

108(50.0) 46(21.3) 26(12.0) 36(16.7)

5. Being so restless that it is hard to sit still

6. Becoming easily annoyed or irritable 56(25.9) 76(35.2) 30(13.9) 54(25.0)

7. Feeling afraid, as if something awful might happen 84(38.9) 56(25.9) 32(14.8) 44(20.4)

According to PHQ-9, 46.2% (n=100) of the respondents had no depression, 26.9% (n=58) had
mild depression, 20.4% (n=44) had moderate depression while 6.5% (n=14) had moderately
severe depression and none had severe depression for the past few weeks.These results are
showed here in the underlying table 4;

TABLE 4: n(%) Depression

Table No depression 100(46.3)

Mild depression 58(26.9)

Moderate depression 44(20.4)

Moderately-Severe 14(6.5)
depression

Total 216(100.0)
 DepressionScoreIn
No depression
Mild depression
Moderate depression
Moderately-Severe depression

Table 5; Adaptation of Patient Health Questionnaire (PHQ-9):

Questions: Not at Several More Nearly

Over the last 2 weeks, how often have you been all days than everyda
bothered by any of the following problems? half the y
n(%) n(%) time
n(%) n(%)
1. Little interest or pleasure in doing things 70 78 36 32 (14.8)

(32.4) (36.1) (16.7)

2. Feeling down, depressed, or hopeless 82 72 28 34 (15.7)
(38.0) (33.3) (13.0)

3. Trouble falling or staying asleep, or sleeping too much 80 52 42 42 (19.4)

(37.0) (24.1) (19.4)

4. Feeling tired or having little energy 40 66 62 48 (22.2)

(18.5) (30.6) (28.7)

5. Poor appetite or overeating 72 64 48 32 (14.8)

(33.3) (29.6) (22.2)

6. Feeling bad about yourself — or that you are a failure or 90 60 28 38 (17.6)

have let yourself or your family down
(41.7) (27.8) (13.0)

7. Trouble concentrating on things, such as reading the 100 52 34 30 (13.9)

newspaper or watching television
(46.3) (24.1) (15.7)

8. Moving or speaking so slowly that other people could have 134 40 28 14 (6.5)
noticed? Or the opposite — being so fidgety or restless that (62.0)
(18.5) (13.0)
you have been moving around a lot more than usual

9. Thoughts that you would be better off dead or of hurting 142 26 20 (9.3) 28 (13.0)
yourself in some way (65.7) (12.0)

Additional question Somew Very Extremel

Not hat difficult y difficult
difficult atdifficult
all
n(%)
n(%)
n(%) n(%)
 If you checked off any problems, how difficult have these (44.4) (23.1) (18.5) (13.9)
problems made it for you to do your work, take care of
things at home, or get along with other people?

There’s significant relation between gender and depression prevalence as the chi square test is less than
.005 (it is 0.001). The prevalence of moderately severe depression is much more in males(n=12/96) than
that in females(n=2/120) while the prevalence of mild depression is higher in females(n=42/120) than
males(n=16/96). There’s more prevalence of depression in females than males as a whole.

Discussion:
Medical students face significant emotional and mental challenges due to the demanding nature of
academic activities of this journey. Excessive burnout, emotional exhaustion and a lack of adequate time
of self-care and relaxation is a common experience among medical students. Previous studies have
highlighted considerable changes experienced by medical students in their lifestyle, mood and health
even in the early period of medical studies which affects their mental well-being significantly[12-13].

Our study found significant patterns in the prevalence of anxiety and depression among medical
students. Based on the GAD-7 questionnaire, 24.1% of participants experienced severe anxiety and 12%
reporting moderate anxiety. These results are consistent with those of a meta-analysis by Quek et al.
(2019), analysing the data from 69 studies comprising 40438 medical students, which found that anxiety
is a global concern among medical students, with varying prevalence rates across different countries and
contexts. The comparatively higher mental health burden in medical students is highlighted by these
findings[14].

Regarding depression, our results showed that 46.3% of participants had no depression, while 26.9%
reported mild depression and 6.5% experienced moderately-severe depression. These findings are in
consistency with those of Azad et al.,(2017) who found significant levels of both anxiety and depression
among medical students at a private medical college, although our study observed a lower prevalence of
severe depression which may be associated with the factor of being a student at government medical
college compared to the case of private medical college with extra psychological burden of expenses
and family response[8].

A significant finding observed in our study was the gender difference in the prevalence of depression(Chi
square test=0.001), where moderately severe depression was more prevalent among male students
(12.5%) compared to females (1.7%), while females were more likely to experience mild depression
(35%). This gender disparity is consistent with the results of Rehmani et al.,(2018) who reported similar
trends in a study on medical students in Pakistan[15]. The higher prevalence of anxiety and depression
among females may be attributed to the sociocultural factors or the differing coping mechanisms
influencing emotional expression.

Interestingly, first-year students reported the highest levels of anxiety, with 29.6% experiencing minimal
anxiety and 28.7% experiencing mild anxiety. These findings align with those of Moutinho et al.(2017).
and Puthran et al.(2016). who noted that anxiety and depression were particularly prevalent among
medical students of earlier semesters, which is most likely due to the challenges faced by them in
adjusting to the medical school environment[16-17].

These findings underscore the need and importance of early intervention and provision of mental health
services tailored to medical students, more specifically to those in their early years of medical studies.
Referring to the high prevalence of mental health burden in this population, relevant authorities must
take proactive measures to reduce the burden of anxiety and depression, and to ensure a mental health
supportive environment throughout their academic journey.

References:
1. Raja S, Balasubramanian G, Jamuna Rani R. Prevalence of depression, anxiety
and stress among private medical college students in South India: A cross-
sectional study. J Educ Health Promot. 2022;11:373.
doi:10.4103/jehp.jehp_393_22
2. Mao Y, Zhang N, Liu J, Zhu B, He R, Wang X. A systematic review of depression
and anxiety in medical students in China. BMC Med Educ. 2019;19(1):327.
doi:10.1186/s12909-019-1744-2
3. Beshr MS, Beshr IA, Al-Qubati H. The prevalence of depression and anxiety
among medical students in Yemen: A cross-sectional study. J Affect Disord.
2024;352:366-370. doi:10.1016/j.jad.2024.02.080
4. Phomprasith S, Karawekpanyawong N, Pinyopornpanish K, et al. Prevalence and
Associated Factors of Depression in Medical Students in a Northern Thailand
University: A Cross-Sectional Study. Healthcare. 2022;10(3):488.
doi:10.3390/healthcare10030488
5. Shao R, He P, Ling B, et al. Prevalence of depression and anxiety and correlations
between depression, anxiety, family functioning, social support and coping styles
among Chinese medical students. BMC Psychol. 2020;8(1):38.
doi:10.1186/s40359-020-00402-8
6. Mhata NT, Ntlantsana V, Tomita AM, Mwambene K, Saloojee S. Prevalence of
depression, anxiety and burnout in medical students at the University of
 Namibia. South Afr J Psychiatry SAJP J Soc Psychiatr South Afr. 2023;29:2044.
doi:10.4102/sajpsychiatry.v29i0.2044
7. Mirza AA, Baig M, Beyari GM, Halawani MA, Mirza AA. Depression and Anxiety
Among Medical Students: A Brief Overview. Adv Med Educ Pract. 2021;12:393-
398. doi:10.2147/AMEP.S302897
8. Azad N, Shahid A, Abbas N, Shaheen A, Munir N. ANXIETY AND DEPRESSION IN
MEDICAL STUDENTS OF A PRIVATE MEDICAL COLLEGE. J Ayub Med Coll
Abbottabad. 2017;29(1):123-127.
9. Kaggwa MM, Najjuka SM, Ashaba S, Mamun MA. Psychometrics of the Patient
Health Questionnaire (PHQ-9) in Uganda: A Systematic Review. Front Psychiatry.
2022;13:781095. Published 2022 Mar 7. doi:10.3389/fpsyt.2022.781095
10. Spitzer RL, Kroenke K, Williams JBW, and the Patient Health Questionnaire
Primary Care Study Group. Validation and Utility of a Self-report Version of
PRIME-MD: The PHQ Primary Care Study. JAMA. 1999;282(18):1737–1744.
doi:10.1001/jama.282.18.1737
11. Spitzer RL, Kroenke K, Williams JBW, Löwe B. A Brief Measure for Assessing
Generalized Anxiety Disorder: The GAD-7. Arch Intern Med. 2006;166(10):1092–
1097. doi:10.1001/archinte.166.10.1092
12. Muzafar Y, Khan HH, Ashraf H, et al. Burnout and its Associated Factors in
Medical Students of Lahore, Pakistan. Cureus. 2015;7(11):e390. Published 2015
Nov 29. doi:10.7759/cureus.390
13. Wolf TM, Kissling GE. Changes in life-style characteristics, health, and mood of
freshman medical students. J Med Educ. 1984;59(10):806-814.
doi:10.1097/00001888-198410000-00005
14. Quek TT, Tam WW, Tran BX, et al. The Global Prevalence of Anxiety Among
Medical Students: A Meta-Analysis. Int J Environ Res Public Health.
2019;16(15):2735. Published 2019 Jul 31. doi:10.3390/ijerph16152735
15. Rehmani N, Khan QA, Fatima SS. Stress, Anxiety and Depression in students of a
private medical school in Karachi, Pakistan. Pak J Med Sci. 2018;34(3):696-701.
doi:10.12669/pjms.343.14664
16. Moutinho IL, Maddalena NC, Roland RK, et al. Depression, stress and anxiety in
medical students: A cross-sectional comparison between students from different
semesters. Rev Assoc Med Bras (1992). 2017;63(1):21-28. doi:10.1590/1806-
9282.63.01.21
17. Puthran R, Zhang MW, Tam WW, Ho RC. Prevalence of depression amongst
medical students: a meta-analysis. Med Educ. 2016;50(4):456-468.
doi:10.1111/medu.12962