Abstract
Background:
Medical students globally experience high levels of stress during training, often leading to anxiety and depression. Many students with mental health concerns do not seek treatment. Thus, understanding the barriers to accessing mental health care is crucial.
Aims:
To identify the barriers to seeking professional mental health care among medical students in central India.
Method:
This cross-sectional study was conducted among 409 medical students at a tertiary care hospital in central India. The barriers to seeking mental health care were assessed using the Barrier to Access to Care Evaluation (BACE) scale. Qualitative data were gathered through open-ended question. The multivariate binary logistic regression model was performed to determine the factors associated with the practice of not seeking mental health care despite the need, along with descriptive analysis.
Results:
One-fourth of the participants reported not seeking care for mental health illness despite having need. Major barriers identified included attitudinal factors, such as wanting to solve problems independently (83.6%) and believing the problem would improve on its own (68.9%). Stigma-related barriers involved concerns about family perceptions (44.5%) and fear of being seen as weak (43.3%). Instrumental barriers included financial costs (23.5%) and lack of support (23.5%). Moderate psychological distress was associated with nearly five times higher odds, severe distress with nearly seven times higher odds of not seeking professional help.
Conclusion:
The study highlights significant attitudinal and stigma-related barriers preventing medical students from seeking mental health care. These findings underscore the need for institutional policies promoting mental health literacy, destigmatization, and early intervention to improve mental health outcomes and ensure the well-being of medical students.
Keywords: Barrier to care, medical education, medical students, mental health services, treatment barriers
INTRODUCTION
Medical students worldwide experience significant stress during their training period, leading to substantial psychological morbidity.[1,2] Depression and anxiety are the most frequently reported mental health disorders in medical students worldwide.[3,4] A systematic review in India revealed the pooled prevalence of anxiety and depression was 34.5% and 39.2%, respectively, among medical students.[5] Further evidences indicate that medical students experience higher rates of depression and anxiety disorders in comparison with the general population.[6]
This growing concern is further underscored by international data, where a systematic review across 43 countries found that 11.1% medical students reported suicidal ideation. Despite this high burden, only 15.7% of students who were identified as having depression sought professional help.[7] Untreated mental health issue not only affects students well-being but also may contribute to an increased likelihood of medical errors, further jeopardizing patient safety.[8] Despite this, many medical students forego getting proper mental health care and instead self-medicate or ask friends or coworkers for advice.[9]
Although the burden of mental disorders in medical students is well studied, research on barriers to accessing care for mental health issues is mostly limited to the high-income countries.[10] Studies from India have identified stigma, confidentiality concerns, and time constraints as leading barriers among postgraduate trainees in North India[11] and undergraduate students in South India.[12,13] Additionally, existing research focuses only on students who recognize the need for help, overlooking those who may have mental health concerns but are unaware of or reluctant to seek care.[13]
While studies from North and South India have highlighted significant barriers, the sociocultural dynamics in Central India may differ, necessitating a region-specific approach to better understand the unique challenges faced by medical students in this area. Understanding these context-specific barriers is essential for informing institutional mental health policies, designing targeted interventions, and strengthening supportive environments within medical education.
In this context, the present study aims to determine the proportion of undergraduate medical undergraduates who do not seek professional help despite the need for mental health issue and to assess the factors, such as sociodemographic, behavioral factors, and psychological distress, that may contribute to the decision to avoid seeking care in a tertiary care institute in central India. Additionally, the study explores the barriers to seek mental health care using a mixed-methods approach, incorporating quantitative assessment through the Barriers to Access to Care Evaluation (BACE) scale and qualitative responses to an open-ended question for deeper contextual understanding.
METHODOLOGY
Study design: Cross-sectional survey of medical students at a tertiary care hospital in central India was conducted from June to September 2023.
Study setting: The study was conducted at a tertiary care hospital in Central India, admitting 125 MBBS students annually through a national-level competitive examination, from various parts of the country.
Study participants: All students currently pursuing MBBS in the institute constituted the study population.
Sample size and sampling: For calculating sample size, assuming the expected population standard deviation was observed to be 5.03 from a study by Arun et al. (2022)[14] among medical students, with a design effect (DEFF) of 2. The required sample size for estimating mean with 95% confidence and a precision of 0.7 was 397. Assuming nonresponse rate of 20%, the sample size was adjusted to 477. To achieve this, we included all students currently pursuing MBBS at the institute.
Data Collection: The data collection tool was circulated by the investigator as a Google Form to medical students via official WhatsApp groups. Participants were requested to complete it at their convenience. To improve the response rate, three weekly reminders were sent. Consent form and participant information sheet were incorporated into the Google Form. Participants provided online consent, following which they were asked to complete the questionnaire. The confidentiality was maintained throughout data collection and responses were stored in file protected by password on the investigator’s desktop. The study was approved by Institutional Ethics Committee.
Study tool: The semi-structured questionnaire included sections on basic demographic information like age, gender, semester, family history of mental disorder, and currently seeking mental health care. Level of psychological distress was measured using Kessler Psychological Distress Scale (K10), a self-rated 10-item tool focused on symptoms over past four weeks with strong internal consistency with a Cronbach’s alpha of 0.93. Scores range from 10 to 50, with higher scores indicating greater psychological distress. Scores are categorized from likely well (10–19) to likely having a severe disorder (30–50).[15] Health seeking behavior was explored by asking the question “During the past 12 months, was there any time when you needed mental health services or counselling for yourself but didn’t seek it?” This was followed by an open-ended question for those who answered “yes” to the above question, “What could be the reasons for not seeking professional mental health even if the need is felt for it ?”
The BACE v3 scale, a self-rated, 30-item tool, was used to assess perceived barriers to seeking mental health care, excluding six irrelevant items (5, 14, 24, 27, 28, and 29) for students as they enquired about employment and barriers related to children.[16] This scale has been validated in multiple international settings, demonstrating good internal consistency and reliability.[16] The scale has also been used in Indian settings, including studies conducted on medical students.[13] The scale measured barriers in three domains: stigma, attitudinal, and instrumental, with responses scored from 0 to 3 as follows: 0—not at all, 1—quite a little, 2—quite a lot, and 3—a lot. For the purpose of our analysis, we combined scores of 2 and 3 to represent major barrier. In the analysis, we considered 0—not at all as not being a barrier, 1—quite a little as a minor barrier, 2—quite a lot, and 3—a lot as a major barrier.
Data Analysis: Statistical analysis was conducted using IBM SPSS version 21. The descriptive analysis (number and proportion) summarized barriers and health-seeking behavior. BACE scores were summarized using mean and standard deviation or median and IQR if the data followed non-normal distribution. The relationship between not seeking mental health care despite need and independent variables was analyzed using the Chi-square test. The multivariate binary logistic regression model was performed to determine the factors associated with the practice of not seeking mental health care despite need. Odds ratios (OR) with 95% confidence interval (CI) were estimated and P value < 0.05 was considered significant. Qualitative data from the open-ended questions were analyzed by two researchers independently. The investigators went through qualitative responses iteratively, with discrepancies resolved through discussion. The codes emerging from data were identified through a hybrid approach, combining both inductive coding and deductive coding. Similar codes were grouped into themes and relevant verbatim quotes for each theme were presented. The thematic analysis approach was used for analyzing the qualitative data.
RESULT
The study had a response rate of 78.5%, with 409 out of 524 students completed the questionnaire. Of the 115 nonrespondents, eight did not consent, and the remaining did not respond to repeated requests. Data were collected through a self-reported survey using a semi-structured questionnaire, followed by an open-ended question. The majority of the students were males (274, 66.9%), under 23 years (352, 86.1%), belonging to urban areas (313, 76.5%). Alcohol use was reported by 15.4% (63), and tobacco use was reported by 5.9% (24), while 12.2% (50) had a family history of mental health disorders.
Nearly one-fourth (108, 26.4%) of students did not seek professional mental health services despite feeling the need in the past year. Older age group (>23 years), tobacco use, alcohol use, positive family history of mental health illness, and severe psychological distress were significantly associated with not seeking professional help. However, gender, place of residence, and caste did not show any significant association with seeking mental health care services [Table 1].
Table 1.
Association between not seeking professional help for mental health services and sociodemographic and behavioral factors among medical students in a tertiary care hospital in Central India
| Total | Did not seek help even if need was felt |
P* | ||
|---|---|---|---|---|
| No n (%) | Yes n (%) | |||
| Total study population | 409 | 301 (73.6) | 108 (26.4) | |
| Age group | <0.001* | |||
| ≤19 years | 175 | 148 (84.6) | 27 (15.4) | |
| 20 to 22 years | 177 | 116 (65.5) | 61 (34.5) | |
| ≥23 years | 57 | 37 (64.9) | 20 (35.1) | |
| Gender | 0.202 | |||
| Male | 274 | 207 (75.5) | 67 (24.5) | |
| Female | 135 | 94 (69.6) | 41 (30.4) | |
| Area of residence | 0.721 | |||
| Rural | 96 | 72 (75.0) | 24 (25.0) | |
| Urban | 313 | 229 (73.2) | 84 (26.8) | |
| Year | <0.001* | |||
| First year | 129 | 111 (86.0) | 18 (14.0) | |
| Second year | 100 | 75 (75.0) | 25 (25.0) | |
| Third year | 82 | 57 (69.5) | 25 (30.5) | |
| Final year | 81 | 48 (59.3) | 33 (40.7) | |
| Intern | 17 | 10 (58.8) | 7 (41.2) | |
| Caste | 0.546 | |||
| General | 218 | 155 (71.1) | 63 (28.9) | |
| Other Backward Caste | 115 | 89 (77.4) | 26 (22.6) | |
| Scheduled Caste | 53 | 41 (77.4) | 12 (22.6) | |
| Scheduled Tribe | 23 | 16 (69.6) | 7 (30.4) | |
| Tobacco use | 0.026* | |||
| No | 385 | 288 (74.8) | 97 (25.2) | |
| Yes | 24 | 13 (54.2) | 11 (45.8) | |
| Alcohol use | <0.001* | |||
| No | 346 | 271 (78.3) | 75 (21.7) | |
| Yes | 63 | 30 (47.6) | 33 (52.4) | |
| Positive family history | <0.001* | |||
| No | 359 | 275 (76.6) | 84 (23.4) | |
| Yes | 50 | 26 (52.0) | 24 (48.0) | |
| Currently seeking help for mental health issues | <0.001* | |||
| No | 370 | 282 (76.2) | 88 (23.8) | |
| Yes | 39 | 19 (48.7) | 20 (51.3%) | |
| Psychological distress based on K10 scale† | <0.001* | |||
| Normal | 226 | 197 (87.2) | 29 (12.8) | |
| Mild distress | 76 | 55 (72.4) | 21 (27.6) | |
| Moderate distress | 48 | 25 (52.1) | 23 (47.9) | |
| Severe distress | 59 | 24 (40.7) | 35 (59.3) | |
*P calculated using the Chi-square test for categorical variables. †Psychological Distress (K10): Based on the K10 scale, where normal (score 10–19), mild distress (20–24), moderate distress (25–29), and severe distress (30–50)
The multivariate logistic regression analysis showed that individuals with moderate psychological distress had nearly five times higher odds (OR = 4.992, 95% CI: 2.428–10.263, P < 0.001), and those with severe distress had nearly seven times higher odds (OR = 6.771, 95% CI: 3.300–13.894, P < 0.001) of not seeking professional help compared to those with no distress. Alcohol use was associated with more than twice the odds of not seeking help (OR = 2.270, 95% CI: 1.104–4.669, P = 0.026). Other variables, such as age, gender, academic year, tobacco use, and positive family history, did not show significant associations. These factors accounted for 26.4% of the explained variability in predicting not seeking professional mental help with LR Chi2 (8) = 81.391, P < 0.001 (Nagelkerke R2 = 0.264) [Table 2].
Table 2.
Factors influencing the likelihood of not seeking professional help for mental health services among medical students in a tertiary care hospital in Central India: a multivariate logistic regression analysis
| Total | Did not seek help despite need (%) | Unadjusted OR* (95% CI) | Adjusted OR† (95% CI) | P | |
|---|---|---|---|---|---|
| Age group | |||||
| ≤19 years | 175 | 27 (15.4) | 1 | ||
| 20-22 years | 177 | 61 (34.5) | 2.883 (1.724–4.820) | 1.603 (0.745–3.450) | 0.228 |
| ≥23 years | 57 | 20 (35.1) | 2.963 (1.499–5.856) | 1.212 (0.394–3.730) | 0.738 |
| Gender | |||||
| Male | 274 | 67 (24.5) | 1 | ||
| Female | 135 | 41 (30.4) | 1.348 (0.852–2.132) | 1.092 (0.638–1.870) | 0.748 |
| Year | |||||
| First year | 129 | 18 (14.0) | 1 | ||
| Second year | 100 | 25 (25.0) | 2.056 (1.049–4.029) | 1.305 (0.607–3.806) | 0.496 |
| Third year | 82 | 25 (30.5) | 2.705 (1.364–5.365) | 1.280 (0.497–3.293) | 0.609 |
| Final year | 81 | 33 (40.7) | 4.240 (2.177–8.256) | 1.473 (0.513–4.233) | 0.472 |
| Intern | 17 | 7 (41.2) | 4.317 (1.456–12.797) | 1.886 (0.424–8.392) | 0.405 |
| Tobacco use | |||||
| No | 385 | 97 (25.2) | 1 | ||
| Yes | 24 | 11 (45.8) | 2.512 (1.090–5.792) | 0.605 (0.209–1.753) | 0.354 |
| Alcohol use | |||||
| No | 346 | 75 (21.7) | 1 | ||
| Yes | 63 | 33 (52.4) | 3.975 (2.278–6.935) | 2.270 (1.104–4.669) | 0.026* |
| Positive family history | |||||
| No | 359 | 84 (23.4) | 1 | ||
| Yes | 50 | 24 (48.0) | 3.022 (1.648–5.541) | 1.662 (0.825–3.348) | 0.155 |
| Psychological distress based on K10 scale† | |||||
| Normal | 226 | 29 (12.8) | 1 | ||
| Mild distress | 76 | 21 (27.6) | 2.594 (1.373–4.900) | 2.073 (1.067–4.021) | 0.031* |
| Moderate distress | 48 | 23 (47.9) | 6.250 (3.143–12.429) | 4.992 (2.428–10.263) | <0.001* |
| Severe distress | 59 | 35 (59.3) | 9.907 (5.175–18.966) | 6.771 (3.300–13.894) | <0.001* |
*Unadjusted OR: Odds ratio calculated without controlling for other variables. †Adjusted OR: Odds ratio adjusted for age, gender, year of study, alcohol use, tobacco use, family history, and psychological distress. ‡Psychological Distress (K10): Distress based on the K10 scale, where normal (score 10–19), mild distress (20–24), moderate distress (25–29), and severe distress (30–50). §P: Calculated using logistic regression analysis. CI: Confidence interval
Barriers to accessing professional mental health care—Using the BACE scale
The BACE scale revealed a total mean score of 14.3 ± 11.4. Attitude related barriers had highest mean score (8.0 ± 5.4), followed by stigma-related (4.4 ± 4.9) and instrumental-related barriers (1.9 ± 2.8). Common attitudinal barriers were “Wanting to solve the problem on my own” (83.6%), “Thinking the problem would get better by itself” (68.9%), and “Preferring to get help from family or friends” (68.4%). Stigma-related barriers included “Concern about what my family might think, say, do or feel” (44.5%), “Concern that I might be seen as weak for having a mental health problem” (43.3%), and “Concern that people I know might find out” (39.1%). Among the instrumental-related barriers, the most common ones were “Being too unwell to ask for help” (23.9%), “Not being able to afford the financial costs involved” (23.5%), and “Having no one who could help me get professional care” (23.5%) [Table 3 and Figure 1].
Table 3.
Barrier to Access to Care Evaluation (BACE) scale scores among medical students in a tertiary care hospital in Central India
| Variable | Not a barrier (not at all stopped me) | Minor barrier (stopped me a little) | Major barrier (stopped me quite a lot and a lot) | Mean (SD) |
|---|---|---|---|---|
| Total score* | 14.3 (11.4) | |||
| Total score (median, Q1–Q3) | 13.0 (5–21) | |||
| Total attitudinal score† | 8.0 (5.4) | |||
| Total attitudinal score (median, Q1–Q3) | 8.0 (4–11) | |||
| Wanting to solve the problem on my own | 67 | 114 | 228 | 1.7 (1.0) |
| Thinking the problem would get better by itself | 127 | 124 | 158 | 1.2 (1.0) |
| Preferring to get help from family or friends | 129 | 123 | 157 | 1.2 (1.0) |
| Dislike of talking about my feelings, emotions or thoughts | 199 | 120 | 90 | 0.8 (1.0) |
| Thinking I did not have a problem | 198 | 121 | 90 | 0.8 (1.0) |
| Preferring to get alternative forms of care (e.g., traditional/religious healing or alternative/complementary therapies) | 231 | 105 | 73 | 0.7 (0.9) |
| Thinking that professional care probably would not help | 278 | 77 | 54 | 0.5 (0.8) |
| Concerns about the treatments available (e.g., medication side effects) | 265 | 96 | 48 | 0.5 (0.8) |
| Having had previous bad experiences with professional care for mental health | 335 | 49 | 25 | 0.3 (0.6) |
| Fear of being put in hospital against my will | 309 | 66 | 34 | 0.4 (0.7) |
| Total stigma score‡ | 4.4 (4.9) | |||
| Total stigma score (median, Q1–Q3) | 3.0 (0–7) | |||
| Concern about what my family might think, say, do or feel | 227 | 101 | 81 | 0.7 (0.9) |
| Concern that I might be seen as weak for having a mental health problem | 232 | 117 | 60 | 0.6 (0.8) |
| Concern that people I know might find out | 249 | 104 | 56 | 0.6 (0.8) |
| Not wanting a mental health problem to be on my medical records | 259 | 98 | 52 | 0.5 (0.8) |
| Feeling embarrassed or ashamed | 255 | 104 | 50 | 0.5 (0.8) |
| Concern about what my friends might think, say or do | 268 | 95 | 46 | 0.5 (0.8) |
| Concern that I might be seen as “crazy” | 282 | 84 | 43 | 0.4 (0.7) |
| Concern that people might not take me seriously if they found out I was having professional care | 260 | 114 | 35 | 0.5 (0.8) |
| Total instrumental score§ | 1.9 (2.8) | |||
| Total instrumental score (median, Q1–Q3) | 1.0 (0–3) | |||
| Not being able to afford the financial costs involved | 313 | 62 | 34 | 0.4 (0.7) |
| Being too unwell to ask for help | 311 | 67 | 31 | 0.3 (0.7) |
| Having no one who could help me get professional care | 313 | 66 | 30 | 0.3 (0.7) |
| Being unsure where to go to get professional care | 295 | 85 | 29 | 0.4 (0.7) |
| Professionals from my own ethnic or cultural group not being available | 332 | 54 | 23 | 0.3 (0.6) |
| Problems with transport or travelling to appointments | 333 | 57 | 19 | 0.3 (0.6) |
*Total Score: The sum of individual responses for barriers to mental health care, with higher scores indicating greater perceived barriers. †Total Attitudinal Score: The sum of responses related to attitudes toward mental health care (e.g., preferences for alternative treatments or self-reliance). ‡Total Stigma Score: The sum of responses related to stigma regarding mental health treatment. §Total Instrumental Score: The sum of responses related to access and availability issues, including cost, availability of services, and transportation. SD=Standard deviation
Figure 1.
Barrier to Access to Care Evaluation (BACE) among medical students in a tertiary care hospital in Central India
The majority of the students reported family members (33.7%, n = 138) as the preferred choice to approach in case of any mental health issue, followed by friends (27.9%, n = 114) and health care provider (14.2%, n = 58) [Figure 2].
Figure 2.
Preferred choice in case of mental health issues among medical students in a tertiary care hospital in Central India
Qualitative data analysis to understand barriers to accessing professional mental health care
A total of 356 responses were received for the open-ended question. The length of the responses ranged from a minimum of one word to a maximum of 77 words. These responses were analyzed qualitatively to identify emerging themes. Following major themes emerged from the responses to the open-ended questions-
Social stigma: Social stigma emerged as the major barrier to seeking help for mental health problems. A major concern of most of the students was the fear of being judged, being treated differently and being considered weak by others which prevented them from seeking care. The students said, “Fear of being labelled as diseased,” “I think people will call them crazy,” “Not being able to be open to the professionals... I might seem weak to the professional if I cry or may be my reason is insane,” “Majority doesn’t seek professional care because of the fear of being termed as mentally ill,” “what others will think about me when they get to know I am getting professional help.”
Confidentiality concern: Students also reported that they find it difficult to open up in front of doctors/psychologists/therapists who are strangers and do not know anything about them. They also expressed concern that approaching somebody for help might expose their personal issues in front of everyone, and they might consider them as crazy as a 21-year-old male medical student said, “Just the fear of others finding out about my problem”
Some even reported that they are hesitant to seek care at their own institute due to the perceived fear of revealing their mental health status in front of their known teachers. “If I go to psychiatric in our college and tell them about my problems they may start seeing or treating me differently because they are our teachers as well”
Poor perceived need for professional help: Some participants did not perceive the need for seeking professional help and reported that whatever situation they are going through will be resolved with time as 18-year-old medical student said, “Problems get solved on its own many times with the help of friends and family.” “I think one must be strong enough to deal with personal problems and observe themselves what makes them out of it. I am just a good observer of myself and environment so I don’t seek the help.” Some participants perceived that the severity of problem is less when compared to the problems other people have to go through, as 19-year-old female medical student said, “Feeling it will get better on its own. Feeling that this is very minute compared to the things that many people have to go through and I should just keep it in and strive through”
Self-reliance: Respondents cited they want to solve the problem autonomously as cited by some students “I think I’m strong enough to take care of these problems,” “I feel that I am strong enough to handle things on my own.” Another female student mentioned “I think one must be strong enough to deal with personal problems and observe themselves what makes them out of it. I am just a good observer of myself and environment so I don’t seek the help.”
Lack of trust in the provider: Respondents also cited lack of trust in the healthcare provider as a 20-year-old medical student said, “not sure whether they will be properly understood and be given appropriate treatment.”
Lack of perceived threat: Some students did not consider mental health problems as a significant health issue and perceived it as part of routine stress that anyone could encounter during everyday chores. An 18-year-old female student said, “I am not comfortable with accepting that mental health is a kind of disorder and we should treat it and think of it as only stress.” A few students also cited not knowing when to seek help, as stated by a few as “Not knowing what’s normal n what’s abnormal,” “not know about disease clearly.”
Fear of Medication: The long duration of treatment, dependency on medications and their side effects, and not being sure of the effectiveness of medicine were some of the reasons cited by participants for not preferring to seek care even if they were having mental distress. A 24-year-old male student said, “Fear of need to take medicines lifelong and not be able to discontinue the medicine and come out of the disease.” Another 22-year-old female student opined that the reason for not seeking professional help could be, “Medications make us drowsy and have other side effects.”
Prefer to take support from family and friends: Some participants believed that family and friends are the best to share about their mental health issues for two reasons. First, they already knew them and can understand their problems very well. Second, they feel more comfortable sharing their concerns and griefs as it ensures confidentiality as well.
Other structural barriers reported were affordability of treatment and consultation, finding time for a consultation from busy academic activities and lack of support from the family as the medical students said, “can’t afford time from the busy schedule,” “no time for going to OPD,” “therapy is expensive,” “Lack of availability of consultants as students have to wait for hours and hours to get consultation sitting outside the cabin, as they have to attend clinics and classes for attendance issues again triggering their mental health.” Though the family is preferred by many for consultation regarding mental health issues, it has also been reported that unsupportive families become the major barrier which hinders care seeking from mental health professionals. According to another 21 year old female student, “His or her family members, friends think they had any serious problem so they may unnecessarily concern them and family members think that when they are present to talk about problem what is the need of other to tell about their problems.”
DISCUSSION
This is one of the few studies in India examining barriers to seeking mental health care among medical undergraduates, especially in the post-COVID era. The key finding was that nearly one-fourth of participants did not seek professional mental health care despite perceived need, a proportion consistent with similar studies in the USA and India (26–37%).[13,17,18] Another study in India reported a dismally low proportion (13%) of postgraduate trainees seeking mental health care.[11] These findings highlight a significant gap in mental healthcare utilization among medical students, even when the need for support is recognized.
While exploring factors associated with this gap, our bivariate analysis revealed that older age, tobacco use, alcohol use, positive family history of mental health illness, and severe psychological distress were significantly associated with not seeking help, the multivariate logistic regression analysis, which adjusted for multiple factors, indicated that moderate psychological distress and severe psychological distress were the only significant predictors of not seeking help. This discrepancy underscores the complexity of mental health help-seeking behavior, where psychological distress appears to be a stronger determinant, and other sociodemographic and behavioral factors being potentially mediated by the level of distress experienced. The students with moderate and severe psychological distress had significantly higher odds of not seeking professional help. This finding is consistent with previous research, which shows that individuals with severe psychological distress are more likely to avoid seeking professional care.[19,20]
Additionally, the decision to exclude the variable currently seeking mental health care from the regression model, despite its significance in the descriptive analysis, was made due to multicollinearity with psychological distress and overlap with other help-seeking behavior.
Barriers to seeking care
Assessment through the BACE scale found that the major barriers to seeking help were attitudinal, followed by stigma-related barriers. Common attitudinal barriers for seeking help, like “wanting to solve their problem on their own” and “thinking that problem would get better by itself,” were consistent with the findings of other studies conducted in Asia and around the world.[12,21,22,23,24] These barriers were further confirmed by our qualitative responses, which suggest that attitude may play a more significant role than stigma in preventing students from seeking help. This reinforces the notion that promoting a positive attitude toward help-seeking behaviors is crucial, perhaps even more so than simply addressing stigma.
“Concern about what my family might think, say, do or feel,” “Concern that I might be seen as weak for having a mental health problem,” and “fear of being stigmatized if others know about his/her condition” were major stigma-related barriers to seeking help. Although stigma-related factors scored lower than attitudinal barriers on the BACE scale, it emerged as a major theme in qualitative exploration. This is in congruence with other studies in which stigma has been identified as the major barrier in seeking mental health care.[19,24,25,26] Stigma from peers and professional colleagues was reported to be another major barrier in a study by Wang et al.[27] among medical students.
About one-fourth of the students reported unaffordability, lack of help to get professional care, and being too unwell to ask for help as barriers. A study in Ohio also reported lack of time and difficulty in accessing services as the common barriers.[18] This suggests that the creation of peer support groups could help facilitate access to care, by reducing barriers like time and accessibility.
In our study, the significant association between severe psychological distress and the lack of help-seeking behavior aligns with the health belief model (HBM), as students experiencing higher levels of distress may be more likely to recognize the severity of their condition but feel they are unable to manage it effectively on their own. Medical students often neglect the severity of their mental health issue, and the level of care required which was reflected in the open-ended responses of the students. They often dismissed their problems as “trivial” and underestimated the level of mental distress as “normal.”[9,28] This shows low perceived severity of mental health issues among medical students. However, barriers, such as attitudinal factors (“wanting to solve the problem on their own”) and stigma-related concerns (e.g., fear of being perceived as weak or shameful), may prevent them from perceiving the benefits of seeking care. This is consistent with the perceived barriers component of the HBM, where even if students perceive a need for care, their attitudes and concerns about stigma could outweigh the perceived benefits of seeking professional help.
The theory of planned behavior (TPB) suggests that behavioral intentions are influenced by attitudes, subjective norms, and perceived behavioral control. According to the TPB, students who have positive attitudes toward seeking help (i.e., believing that it will lead to improvement) are more likely to intend to seek care. Our findings support this model, suggesting that negative attitudes (e.g., “wanting to solve the problem on their own” or “thinking the problem will get better by itself”) and perceived social norms (e.g., fear of being stigmatized by family or peers) play a critical role in deterring students from seeking help. The perceived behavioral control component of TPB suggests that students with limited access to mental health services, financial constraints, or fear of confidentiality breaches might feel they lack the ability to seek help, even if they recognize the need. These findings reflect the intricate relationship between attitudes, norms, and perceived control, which influence students’ decisions to seek or avoid help for mental health issues.
Practical implications
Interventions designed to increase mental healthcare utilization should focus on changing attitudes and addressing stigma. Programs aimed at improving mental health literacy, reducing stigma, and encouraging positive attitudes toward seeking help are essential. As suggested by the HBM, increasing students’ perceptions of severity and susceptibility to mental health issues, alongside demonstrating the benefits of seeking care, could encourage more students to engage with mental health services. Additionally, interventions that focus on improving students perceived behavioral control—such as enhancing access to services and addressing confidentiality concerns—could also facilitate greater help-seeking behavior. The implementation of screening of all medical students at admission and regular annual follow-ups could also be a viable approach to improve perception of susceptibility.
Sofka et al.,[29] in an interventional study, demonstrated that a wellness program with an opt-out option can normalize help-seeking behavior, promote mental well-being and facilitate early identification of mental health issues. The perceived barrier of confidentiality could be addressed by establishment of an off-campus mental healthcare facility, measures such as de-linking medical records of students from administrative records and restricting access to medical records to only the treating professional. This could reduce confidentiality concerns and increase utilization of mental healthcare services among medical students.[9,30]
In addition to the findings of this study, it is worth noting that several mental health programs are currently being implemented at the institute to address the well-being of medical students. These include the mentor–mentee program, which provides students with guidance and emotional support, fostering a sense of connection and reducing isolation. Additionally, the Suicide Gatekeeper Training Program is actively running, aimed at training faculty and students to recognize signs of distress and intervene early. These initiatives are part of a broader effort to improve mental health awareness, reduce stigma, and create a supportive environment for students, encouraging them to seek help when needed.
Strength and limitations
The study used both quantitative and qualitative methods of data collection and analysis, the triangulation of which lends robustness to the study findings. High response rate of ~80% in an online survey and data completeness were some of the strengths of the study. However, nonresponse could be linked to the presence of underlying emotional or mental health issue, unwillingness to participate, or other personal reasons. These factors need to be considered while interpreting the findings of the study.
There were a few limitations in this study. This study was conducted in a single tertiary care hospital in Central India, which could affect the generalizability of the study findings. However, uniformity in undergraduate admissions, teaching, and curriculum across the country could lend external generalizability to the study findings in similar institutional settings. Self-reporting bias could also affect the validity of the responses.
CONCLUSION
This is one of the few studies in India exploring barriers to seeking help for mental illness among medical students. These findings highlight gaps in mental healthcare pathways in an institutional setting. Despite easy access to services and greater awareness of mental health issues and the stigma around it, one-fourth of the medical students did not seek mental health services, when needed. Interestingly, no significant gender differences were observed in the barriers to seeking mental health care. Attitudinal and stigma related barriers were most common. These findings emphasize the need for multifaceted approach, including improved mental health literacy, de-stigmatization, dedicated institutional policy, periodic screening, and normalizing help seeking behavior.
Declaration regarding the use of generative AI
The author(s) attest that there was no use of generative artificial intelligence (AI) technology in the generation of text, figures, or other informational content of this manuscript.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
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