Depression and Stigma in Medical Students at a Private Medical College

Abstract

Objectives:

This study aimed to assess prevalence rate of depression and perceptions regarding stigma associated with depression amongst medical students.

Materials and Methods:

A cross-sectional survey was conducted amongst 331 undergraduate medical students at a private medical college in Gujarat. Data was collected, which comprised of socio-demographic details, Patient Health Questionnaire (PHQ-9), and a 22-item semi-structured questionnaire to assess personal, perceived, and help-seeking stigma. Univariate analysis and chi-square tests were used to test for association between variables.

Results:

Overall prevalence of depression was found to be 64%. Highest level of depression was seen in first year. Moderate to severe depression was found in 26.6% students. 73.3% students felt that having depression would negatively affect their education, and 52.3% saw depression as a sign of personal weakness. Females more strongly believed that students would not want to work with a depressed student (50.9% v/s 36.2%) and that if depressed, they would be unable to complete medical college responsibilities (61.9% v/s 44.1%). With increasing academic year, there was increase in stigma about disclosing depression to friends (P = 0.0082) and increase in stigma about working with a depressed student (P = 0.0067). Depressed students felt more strongly than non-depressed students on 10 items of the stigma questionnaire.

Conclusions:

High stigma exists among students about the causation of depression, and there exists an environment in which students discriminate fellow colleagues based on the presence of depression. This raises need for increasing awareness and support from peers and faculty.

INTRODUCTION

High prevalence of depression among medical students has been noted in earlier studies.[1] Most studies have been conducted in western countries and in other parts of the world.[1,2,3,4] Studies on depression amongst medical students in the Indian subcontinent are scanty.[5,6,7]

Previous studies have found poor utilization amongst medical students, despite the availability of effective medications and confidential mental health services.[8,9] Stigmatizing attitudes about depression and mental health services may represent a barrier to seeking help and support.[9,10] The most frequently cited barriers to using these services in a qualitative study were lack of time, lack of confidentiality, stigma associated with using mental health services, cost of treatment, fear of documentation on academic record, and fear of unwanted intervention.[9]

Schwenk et al.[11] addressed in specific details the perceptions of stigma by depressed medical students that may serve as barriers to seeking help and support. They found that depressed medical students more strongly held several depression stigma beliefs than non-depressed students.[11] There is dearth of epidemiological studies on depression and stigma related to depression and utilization of mental health services amongst medical students in India.

The aims of this study were to identify 1) prevalence rate of depression among medical students, 2) perceived need for psychological help and academic help in medical students, 3) perceptions of medical students regarding stigma associated with depression.

MATERIALS AND METHODS

Subjects and procedures

An anonymous cross-sectional survey was conducted amongst 400 undergraduate medical students enrolled at a private medical college in Gujarat, during the initial part of the academic year between May and June 2012. Of these, 82.7% (n = 331) participated in the survey. Students who were absent on the day of study and could not be contacted during a revisit were not included in the study. Institutional Human Research Ethics Committee approval was obtained prior to the study.

Instruments

The questionnaire included socio-demographic details, Patient Health Questionnaire (PHQ-9),[12] and 22 statements to tap depression-related stigma beliefs. Also, the perceived needs for psychological and academic help over the past 12 months were tapped using yes-no questions.

PHQ-9 is a validated questionnaire to screen for depression. Cut-off scores used were 0-4 for no or minimal depression, 5-9 for mild depression, 10-27 for moderate to severe depression.[12] In comparison to a mental health provider structured interview, scores of 5-9 on PHQ-9 represent respondents with either no depression or sub-threshold depression (minor depression and dysthymia).[12] At a cut off ≥10 on PHQ-9, respondents were most likely to meet DSM-IV criteria for major depressive disorder (likelihood ratio ≥7.1).[12]

Twenty-two statements to tap depression-related stigma were selected based on an earlier study among medical students in US[11] and validated instruments for general population (Depression Stigma Scale[13] and Depression Self-Stigma Scale).[14] The questions related to domains of personal stigma, perceived stigma, and help-seeking stigma and were answered using 3-point Likert scale (Agree, Neither agree nor disagree, Disagree). There were 4 positively worded and 18 negatively worded statements. Disagreement on a positively worded statement and agreement on a negatively worded statement was considered as stigmatized response. The questions were adapted to be contextually relevant to medical students. For example, the statement “Person with depression could snap out of the problem” was changed to “Medical students with depression could come out of depression whenever they want to.”

Statistical analysis

Data was analyzed using Microsoft Excel 2007 and SPSS 14. Univariate analysis was performed and the chi-square test was used to test for association between variables. The threshold for statistical significance was set at the standard P value of 0.05. Responses with missing values were excluded [Table 1]. Ambivalent responses (“Neither agree nor disagree”) were excluded when studying the variance in depression-related stigma beliefs by gender, academic year, and PHQ-9 scores [Tables 2-4].

Table 1.

Study population distribution of depression-related stigma beliefs

Table 2.

Personal stigma beliefs by depression scores^*

Table 4.

Help-seeking stigma beliefs by depression scores^*

RESULTS

A total of 331 participants enrolled in the study. Demographic characteristics of the study sample are represented in Table 5. More than 80% students from each academic year could be included in the study.

Table 5.

Socio-demographic data of the study sample

Prevalence of self-identified depression (PHQ-9 ≥ 5) was found to be 64% [Table 6] with 1^st and 2^nd years students having significantly higher levels than 3^rd and 4^th year students (P = 0.0096, Table 7). Highest level of depression on PHQ-9 was seen in the 1^st year. Prevalence of moderate to severe depression (PHQ-9 ≥ 10) was found to be 26.6% [Table 6].

Table 6.

Gender-wise variation in study variables

Table 7.

Academic year-wise variation in study variables

Need for psychological help and academic help was reported by 42.9% and 55.2% of the students, respectively [Table 6]. There was significant difference in need for academic help by academic year (P = 0.008, Table 7). Students with moderate to severe depression had significantly higher need for psychological help and academic help (P < 0.0001, Table 8).

Table 8.

Depression scores by perceived needs

Study population distribution of depression-related stigma beliefs was calculated [Table 1]. Ambivalent responses on beliefs items ranged from 14.9% to 37.7%. On the personal stigma beliefs, 73.3% students felt that having depression would negatively affect their education, 52.3% saw depression as a sign of personal weakness, 45.4% endorsed ability to come out of depression at will, 41.6% felt that they would be unable to complete responsibilities as well as others, 36% felt students with depression are to blame for their problems, and 34.2% felt they would feel embarrassed or ashamed if depressed.

On the perceived stigma beliefs, 39.3% felt other students would respect their opinion less, 36.4% felt students and teachers would view a depressed student as unable to handle their responsibility, 35% felt students who knew would tell other students or teachers.

On the help-seeking stigma beliefs, 36.2% felt asking for help would mean inadequate coping, 34.7% felt other student asking for help would mean inability to handle stress, 28.6% felt seeking help for depression would make them feel less intelligent, and 28.1% felt telling a counselor or mentor would be risky.

Variance in the depression-related stigma beliefs according to demography and depression scores was analyzed. Female students more strongly felt that students would not want to work with a student who is depressed (P = 0.0341, Table 6) and that if they were themselves depressed, they would be unable to complete medical college tasks and responsibilities (P = 0.0062, Table 6). With increasing academic year, there was increase in stigma about disclosing depression to medical college friends (P = 0.0082, Table 7) and increase in stigma about working with a student who is depressed (P = 0.0067, Table 7).

Ten depression-related stigma beliefs varied significantly according to depression levels. On personal stigma beliefs, [Table 2] students with moderate to severe depression (PHQ-9 ≥ 10) felt more strongly that they would feel embarrassed or ashamed if depressed (P < 0.0001), medical students with depression are to blame for their problems (P = 0.0017) and that depression is a sign of personal weakness (P = 0.023).

With respect to perceived stigma beliefs, [Table 3] students with moderate to severe depression felt more strongly that friends who knew would tell other students or teachers (P = 0.0021), other students would avoid them if discovered that they were depressed (P = 0.01), other students and teachers would view them as unable to handle responsibilities (P = 0.017).

Table 3.

Perceived stigma beliefs by depression scores^*

On help-seeking stigma beliefs, [Table 4] students with moderate to severe depression felt more strongly that telling a counselor would be risky (P = 0.0024), asking for help would mean inadequate coping skills (P = 0.0037), seeing a counselor would mean inability to handle stress of medical school (P = 0.005), seeking help for depression would make them feel less intelligent (P = 0.008).

DISCUSSION

Prevalence of self-identified depression was 64%. 26.6% of the students were likely to meet the standardized criteria for major depression (PHQ-9 score ≥10, likelihood ratio ≥7.1).[12] Prevalence of self-identified depression among medical students in previous studies was between 50% to 70%.[2,5,6,7] High levels of depression across the years also suggest that emotional distress during medical school is chronic and persistent rather than episodic.[15]

Prevalence of self-identified depression was significantly higher in the 1^st and 2^nd years as compared to 3^rd and 4^th years. This finding is consistent with previous studies.[6,7] In contrast to this, Kumar et al.[5] reported higher depression in the 3^rd and 4^th year students. Prevalence of self-identified depression was marginally higher in females, but not reaching statistical significance and consistent with earlier studies.[2,16,17]

Agreement rate on depression as a sign of personal weakness was close to an Indian study in rural community.[18] Agreement rates on ability to snap out of depression and themselves to blame for problems were similar to a study among medical students in Sri Lanka.[19] This suggests high stigma exists among students about the causation of depression. Three fourths of the students felt depression would affect their self-efficacy as noted from agreement rates on negative effect of depression on education, ability to handle responsibilities, and feelings of shame. This suggests that failure to work would make them feel like a failed person.[10,11]

Thirty to 40% students felt that if depressed, other students would respect their opinion less, they won’t be able to handle responsibilities, and other students would not work with them. These findings combined with significantly higher stigma about working with a depressed student in females, and higher stigma with increasing academic year indicates an environment in which students discriminate fellow colleagues based on the presence of depression.

This study provides a view of the stigma perceived by students reporting depression in contrast to non-depressed students. In an environment where students were likely to discriminate fellow colleagues based on the presence of depression, students having higher levels of depression were likely to face higher discrimination.

On personal stigma beliefs, students with moderate to severe depression felt more strongly that they would feel embarrassed or ashamed and they were to blame for their problems. Students feeling embarrassed or ashamed may turn a blind eye towards their problems.[20] This is reflected in help-seeking stigma beliefs; students with moderate to severe depression felt more strongly that confidentiality would not be maintained by friends, teachers, and counselors, and asking for help would make them feel inadequate and less intelligent.

Students with moderate to severe depression had significantly higher need for psychological help; however, due to the high levels of stigmatizing beliefs, they were least likely to seek help. These findings are consistent with a study by Manos et al., which supports a model in which “an individual experiences depressive symptoms, which leads to stigmatizing experiences and an increase in the salience of stigmatizing attitudes about depression, which in turn leads to avoidance.”[21]

Highest levels of self-identified depression and need for academic help were seen in the 1^st year. In an earlier study, 1^st year students indicated experiencing the highest degree of pressure from studies.[22] Students with moderate to severe depression had significantly higher need for academic help.

In conclusion, high stigma exists among students about the causation of depression, and there exists an environment in which students discriminate fellow colleagues based on the presence of depression. Depressed students were more likely to be discriminated, leading to higher salience of certain personal and help-seeking stigma attitudes as compared to non-depressed students. They were least likely to seek treatment and support even though they felt higher needs for psychological help than the non-depressed students. This raises the need for increasing awareness, support from peers and faculty, and improving structure of medical curriculum.

Limitation of the study is that the study was cross-sectional survey. Further longitudinal studies with intervention need to be planned to see the outcome.