|Year : 2010 | Volume
| Issue : 1 | Page : 41-46
Efficacy of behavioral intervention in reducing anxiety and depression among medical students
A Velayudhan1, S Gayatridevi2, Rita Rani Bhattacharjee2
1 Department of Psychology, Bharathiar University, Coimbatore, India
2 Avinashilingam University for Women, Coimbatore, Tamil Nadu, India
|Date of Web Publication||16-Mar-2011|
Department of Psychology, Bharathiar University, Coimbatore - 641 046, Coimbatore
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Now a days, college students frequently have more complex problems than they used to have over a decade ago - greater difficulties in relationships; and more severe problems, such as depression, anxiety and thoughts of suicide. Counseling helps students to understand themselves and the world around them, and to adjust themselves more efficiently and appropriately to other fellow beings. Aim: To determine as to what extent the medical students were able to cope up with their anxiety and depression with the help of counseling. Materials and Methods: In the experimental design 'Before-and -after with control design', Beck Anxiety Inventory and Beck Depression Inventory were administered to 120 medical students who were randomly selected from a private medical college, comprising of 30 males and 30 females in each of the two groups, viz., the experimental group and the control group. Statistical analysis: Means, standard deviations, t test and one-way ANOVA were used to analyze the data. Results: Anxiety and depression among the students were found to be reduced after counseling. Male and female students in the experimental group showed decrease in the levels of anxiety and depression; whereas the control group, which did not get the benefit of counseling, continued to have the same levels of anxiety and depression. Conclusion: Counseling is helpful in building self-confidence and the capacity to adjust, by reducing anxiety and depression among medical college students.
Keywords: Anxiety, depression, intervention, relaxation, yoga
|How to cite this article:|
Velayudhan A, Gayatridevi S, Bhattacharjee RR. Efficacy of behavioral intervention in reducing anxiety and depression among medical students. Ind Psychiatry J 2010;19:41-6
Today, most societies, both in the developed and the developing countries, view adolescents as immature and ill-equipped individuals requiring guidance to help them become responsible members of their communities. In today's world, college students frequently have more complex problems than they used to have over a decade ago, including the typical or expected problems of college student - difficulties in relationships and developmental issues; as well as the more severe problems, such as depression, sexual assault and thoughts of suicide.
Counseling is, in its essence, a 'helping relationship.' The goal of counseling is to help individuals overcome many of their future problems. Counseling service for adults comprises a follow-up service, which may help counselees secure continuing education and assistance for personal and occupational adjustments. Modern counseling is a product of the educational system, which has deep roots in terms of concern for the individual's freedom, rights, dignity and worth as a human being. Counseling in the educational context comprises a very important and vital part of educational activities. Many students at different levels of education have been found to function at levels far below their capacities. Counseling would certainly help brighten the lives of many young individuals. It promotes emotional maturity, personality development, self-responsibility, creativity and ability to solve problems. Educational counseling has emerged as a discipline to provide help to students on campus of schools, colleges and universities, such that they are not tormented by their internal conflicts, do not become cynical and do not resort to self-destructive strategies. In recent times, education has come to have a wider meaning, namely, counseling, for it has increasingly been realized that learning in the ultimate analysis is individual learning or self-learning. The collegiate student is, for all practical purposes, an adult with no adult responsibilities. Thus, a total counseling program at the collegiate level would comprise an extension of the various services provided to the pupils at the earlier stages of their lives.
Anxiety is experienced by every individual at some point or the other in his/ her life. According to Coleman, "Anxiety is an internalized fear aroused by an impulse to commit mistakes."  It is a series of symptoms, which arise from faulty adaptation to the stresses and strains of life. Anxiety is one of the most common problems faced by college students. An author investigated examination-related anxiety experienced by medical students, with the Visual Analogue Scale for Anxiety (VASA) for three situational cues - usual day-to-day anxiety, highest anxiety associated with major exams the previous year and anxiety experienced during the end-of-term examination just completed. , Twenty-eight weeks later, the students rated the anxiety experienced by them during a subsequent end-of-term psychiatry examination. For day-to-day anxiety, most students rated themselves toward the lower end of the VASA, though not markedly higher anxiety during the end-of-term psychiatry examination.
According to Coleman, depression is "an emotional state characterized by extreme dejection, gloomy ruminations, feelings of worthlessness, loss of hope, and often of apprehension."  The World Health Organization has declared depression as the leading cause of disability because of its physical, psychological and social impacts.  The researchers conducted a study on depression among 129 first year psychology students in South Africa.  The results revealed that psychology students reported significantly lower levels of depression than non-psychology students on the Beck Depression Inventory. Students who experience depression may feel an oppressive sense of sadness, fatigue, guilt and hopelessness. Depression is a common experience among college students, with one in seven students experiencing it. Brought on by a combination of students' vulnerable age and the stress and demands of college life, depression and related conditions can strike for the first time in college, or come back to haunt those who had first battled it in high school. Medical students are more prone to depression than their non-medical peers. Researchers noted that depression gets doubled among medical students between the beginning and end of an academic year.  Most people experience feelings of being stressed out or anxious before an important event such as an exam or a class speech. An author pointed out that fear of failure is one of the sources of stress in a medical school.  But many students face more than just normal stress; their lives are filled with overwhelming worrying and fear that are chronic and debilitating.
A researcher studied the relationship between depression and anxiety among undergraduate students in 18 Arab countries by a cross-cultural study.  Beck Depression Inventory was administered to 9,168 participants, comprising 4,230 males and 4,938 females, their ages ranging from 18 to 25 years.  Findings indicated that depression was positively significant and correlated with anxiety. Authors studied the relation of depression and anxiety to life stress and achievement in students.  The result showed that 9% of previously symptom-free students became depressed, and 20% became anxious at a clinically significant level. The explosion in medical knowledge means that every year they need to learn more to update themselves.
The pace of receiving knowledge is faster in a medical college than the student ever faced before. Authors stated that stress, health-related and emotional problems increase during the period of undergraduate medical education.  This can lead to mental distress and has a negative impact on cognitive functioning and learning. Any student who has a scintilla of self-doubt will find that self-doubt got activated and magnified during his/ her education in a medical college. Countless hours spent in the library, harsh exams, competitions, stress and a small-to-non-existent income for several years, sum up the everyday life of many medical students. Researchers found that unlike residents, medical students are not protected by limits on work hours.  Exam anxiety is the emotional reaction that some students face before exams. It has been observed by Morrison that medical students have marked undue stresses during pre-examination and examination period.  Studying itself can be stressful, but researchers found that there were specific health-related effects of medical education, including high levels of anxiety and depression. Suicidal ideation among medical trainees has been investigated less often and only periodically. The National College- Health Assessment Survey found that 9.5% of students preparing for health-related fields reported that they had experienced suicidal ideation.  Emotional intelligence is highly associated with better psychological adjustment. Individuals reporting greater emotional clarity and a greater ability to repair their own emotional states report higher levels of self-esteem, another important indicator of mental health.  Researchers studied the prevalence of emotional disorders using the English version of the General Health Questionnaire-12 among respondents who were medical students at a private medical school in Ipoh, Perak, Malaysia.  The researchers indicated that the prevalence of emotional disorders among the medical students was high (46.2%). Previous studies on the psychological health of physicians shows the medical community exhibits a relatively high level of certain mental health problems, particularly depression, which may lead to drug abuse and suicide.  Counseling programs are essential among students for subjective well-being and mental health. The positive effects of such counseling services and stress management programs are frequently reported.  The authors illustrated the behavioral treatment of medical students and physicians whose debilitating test-related anxiety was associated with their failure to pass the United States Medical Licensing Examination (USMLE).  Treatment featured progressive muscle relaxation, systematic desensitization, the self-control triad, behavioral rehearsal and a psycho-educational component. Ninety-three percent of the clients eventually passed the examination while in treatment. Pass rates for this group were substantially higher than the national average for repeat USMLE test takers.
| Objectives|| |
- To analyze the levels of anxiety and depression among medical students (pre-test and post-test).
- To provide counseling sessions for depression and anxiety.
- To find out the differences in the levels of anxiety and depression among the male and female students before and after the counseling session.
- There will be no significant difference in anxiety between the experimental and control groups before counseling.
- There will be no significant difference in anxiety between the experimental and control groups after counseling.
- There will be no significant difference in depression between the experimental and control groups before counseling.
- There will be no significant difference in depression between experimental and control groups after counseling.
- There will be no significant difference in anxiety among the boys of the experimental and control groups before and after counseling.
- There will be no significant difference in anxiety among the girls of the experimental and control groups before and after counseling.
- There will be no significant difference in depression among the boys of the experimental and control groups before and after counseling.
- There will be no significant difference in depression among the girls of the experimental and control groups before and after counseling.
| Materials and Methods|| |
The sample consisted of 120 medical students; of them, 30 males and 30 females constituted the control group, and 30 males and 30 females constituted the experimental group. These students were randomly selected from the population of a private medical college affiliated to a foreign university.
Beck anxiety inventory (1993):
Aaron Beck devised the Beck Anxiety Inventory in 1993.  It is an inventory of 33 items; it evaluates the most common symptoms of anxiety and panic, such as worry, fear of dying, and a racing heart. The alternatives provided for each statement or symptoms were, "not at all," "somewhat," "moderately" and "a lot." The scale consisted of 6 questions on anxious feelings; 11, on anxious thoughts; and 16, on the physical symptoms of anxiety.
Beck depression inventory (1996):
Aaron Beck devised the revision format of Beck Depression Inventory (BDI) in 1996.  The BDI is a 21-item self-report inventory; it assesses emotional, cognitive and physiological aspects of depression. The questionnaire is composed of items relating to symptoms of depression, such as hopelessness and irritability; of cognition, such as guilt or feelings of being punished; and physical symptoms such as fatigue, weight loss. Each of the 21 items of the BDI attempts to assess an attitude that appears to be specific to depressed people.
The above two questionnaires were administered to the subjects (n= 120) of experimental and control groups before and after counseling. To the experimental group, Counselling, relaxation techniques and meditation were taught and it was ensured that it was practiced. After 1 month, the two questionnaires were once again administered to the subjects of both the groups.
Statistical analysis was done with the help of Statistical Package for Social Sciences [SPSS]. The means and standard deviations, t test and ANOVA were used to find if there were significant difference between the groups.
| Results and Discussion|| |
The mean scores and standard deviations with regard to anxiety and depression were obtained for both the groups of medical students before and after intervention, during which counseling was provided for the experimental group. One-way analysis of variance (ANOVA) was used to test the significance of the difference between the mean scores obtained by medical students in the areas of anxiety and depression. The efficacy of counseling was also compared using a control group. The following results were obtained from the present study.
The means, standard deviations and the F ratio were calculated to find out if the difference in the level of anxiety between the experimental and control groups before counseling was significant. [Table 1] shows that there was no significant difference between the two groups (experimental and control groups). It shows that the groups were homogeneous. Therefore, the hypothesis "There will be no significant difference in anxiety between the experimental and control groups before counseling." is accepted.
|Table 1: Anxiety among students of experimental and control groups before counseling|
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[Table 2] shows the F ratio in one-way analysis of variance. Results showed there was significant difference in the anxiety level after counseling between the experimental and control groups. Since the experimental group was given counseling, they were able to overcome the problems faced by them. The control group did not receive any counseling; their problems remained the same after the test. Therefore, the hypothesis "There will be no significant difference in anxiety between the experimental and control groups after counseling." is rejected.
[Table 3] shows the values of mean, standard deviation and the F ratio of the experimental and control groups before intervention, to find out if there was any significant difference in depression between the two groups. The above table shows there was no significant difference between the two groups (control and experimental) with regard to depression before counseling. As both the groups belong to the same institution and suffer from more or less similar problems, the result indicated that there was no significant difference between them before counseling. Therefore, the hypothesis "There will be no significant difference in depression between the experimental and control groups before counseling." is accepted.
|Table 3: Depression among experimental and control groups before counseling|
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[Table 4] shows the values of mean, standard deviation and the F ratio, which reveals a significant difference in depression between the experimental and control groups. Because of counseling, depression was reduced to a great extent for the experimental group. Therefore, the hypothesis "There will be no significant difference in depression between the experimental and control groups after counseling." is rejected.
|Table 4: Depression among experimental and control groups after counseling|
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[Table 5] shows that there is a significant difference between the level of anxiety experienced before and after counseling among boys. This could be due to guidance and support provided to the boys. The responses were quite similar, both pre-test and post-test. Almost all students had problems regarding their coping up with the foreign syllabus of their MBBS course except a few students who had personal problems also. Without proper support and guidance, the boys in the control group had the same problems as seen in the responses post-test, showing no significant difference before and after the test. Therefore, the hypothesis "There will be no significant difference in anxiety among the boys of the experimental and control groups before and after counseling." is partially accepted.
|Table 5: Anxiety among boys in the experimental and control groups before and after counseling|
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[Table 6] shows the 't' values for the levels of anxiety experienced by the girls of the medical college before and after counseling for both experimental and control groups. The results showed a significant difference in the anxiety levels among the girls in the experimental group before and after counseling, as an effect of counseling. But the control group remained the same with regard to anxious feelings. Therefore, the hypothesis "There will be no significant difference in anxiety among the girls of the experimental and control groups before and after counseling." is partially accepted.
|Table 6: Anxiety among girls in experimental and control groups before and after counseling|
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[Table 7] shows that there is a significant difference in the levels of depression among boys in the experimental group before and after counseling. They were given guidance with regard to learning and routine work in the course of their day-to-day activities. There was no significant difference in the pre-test and post-test levels of depression among boys of the control group. Boys of the medical college seemed to be depressed regarding their academic level, their surroundings, as well as the course that they were undergoing due to their lack of confidence, decision-making ability and willpower as a whole. Therefore, the hypothesis "There will be no significant difference in depression among the boys of the experimental and control groups before and after counseling." is partially accepted.
|Table 7: Depression among boys in experimental and control groups before and after counseling|
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[Table 8] shows the 't' values for the girls in experimental and control groups before and after counseling. Medical students are prone to depression due to hard work, no resting time, Inadequate sleep, fatigue, etc. It is believed that, students' coping strategies and personal health deteriorate as they progress through medical school. Students often dismiss their feelings of despondency as a normal emotional response to medical school education, where they live from test to test and don't take time off for themselves. Almost similar problems were faced by the medical students in this study, wherein it was found that they needed help to overcome such depression, and it was also found that counseling was effective for the students in considerably relieving them from depression and finding solutions of their choice. [Table 8] shows that there was a significant difference in the levels of depression among girls in the experimental group before and after counseling; and there was no significant difference in the pre-test and post-test levels of depression among girls of the control group. Therefore, the hypothesis "There will be no significant difference in depression among the girls of the experimental and control groups before and after counseling." is partially accepted.
|Table 8: Depression among girls in experimental and control groups before and after counseling|
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| Conclusion|| |
The medical students who got the benefit of counseling during the intervention program were found to have lower levels of anxiety and depression at the end of the intervention program when compared to the start of the intervention program. Counseling certainly helped to increase the levels of self-confidence and the ability of adjustment of the medical students. It is suggested that counseling should be an integral part of any educational course, especially professional courses, in order to boost self-confidence and adjustment ability of the students. Relaxation techniques have time and again proved that they are adjunct to medicine in a number of ways; thus they have to be imbibed as a way of life for many to overcome such problems.
| References|| |
|1.||Coleman JC. Abnormal Psychology and Modern Life. Los Angles: Scott Foresman and Co.; 1988. |
|2.||Kidson M, Hornblow A. Examination anxiety in medical students: Experiences with the visual analogue scale for anxiety. Med Educ 1982;16:247-50. |
|3.||Vogelsang J. The visual analog scale: An accurate and sensitive method for self-reporting preoperative anxiety. J Post Anesth Nursing 1988;3:235-9. |
|4.||WHO department of non communicable disease surveillance (August 18th 2006). Available from: http://www.who.int [Last accessed on 2007 Mar 20]. |
|5.||Pillay AL, Edwards SD, Gambu SQ, Dhlomo RM. Depression among university students in South Africa. Psychol Rep 2002;91:725-8. |
|6.||Vitaliano PP, Maiuro RD, Russo J, Mitchell ES, Carr JE, Van Citters RL. A Biopsychosocial model of medical student distress. J Behav Med 1988;11:311-31. |
|7.||Sherina MS, Lekhraj R, Nadarajan K. Prevalence of emotional disorders among medical students in a Malaysian university. Asia Pac Fam Med 2003;2:213-7. |
|8.||Alansari BM. Relationship between depression and anxiety among undergraduate students in eighteen Arab countries: A cross-cultural study. Soc Behav Personal 2005;33:503-12. |
|9.||Beck AT, Steer RA, Brown GK. Manual for the Beck Depression Inventory-II. San Antonio, TX: Psychological Corporation; 1996. |
|10.||Andrews B, Wilding JM. The relation of depression and anxiety to life-stress and achievement in students. Br J Psychol 2004;95:509-21. |
|11.||Dahlin M, Joneborg N, Runeson B. Stress and depression among medical students: A cross-sectional study. Med Educ 2005;39:594-604. |
|12.||Golub JS, Weiss PS, Ramesh AK, Ossoff RH, Johns MM 3 rd . Burnout in residents of otolaryngology-head and neck surgery: A national inquiry into the health of residency training. Acad Med 2007;82:596-601. |
|13.||Morrison J, Moffat K. More on Medical Student stress. Med Educ 2001;35:617-8. |
|14.||Kisch J, Leino EV, Silverman MM. Aspects of suicidal behaviour, depression, and treatment in college students: Results from the spring 2000 national college health assessment survey. Suicide Life Threat Behav 2005;35:3-13. |
|15.||Salovey P, Woolery A, Stroud L, Epel E. Perceived emotional intelligence, stress reactivity and symptom reports: Furthers explorations using the Trait Meta-Mood Scale. Psychol Health 2002;77:611-27. |
|16.||Zaid ZA, Chan SC, Ho JJ. Emotional Disorders among Medical Students in a Malaysian Private Medical School. Sigapore Med J 2007;48:895-9. |
|17.||Tyssen R, Vaglum P. Mental health problems among young doctors: An updated review of prospective studies. Harv Rev Psychiatry 2002;10:154-65. |
|18.||Edelman M, Ficorelli C. A measure of success: Nursing students and test anxiety. J Nurses Staff Dev 2005;21:55-9 |
|19.||Powell DC. Behavioral treatment of medical students and physicians whose debilitating test anxiety was associated with their failure to pass the United States Medical Licensing Examination. USA: USMLE; 2006. |
|20.||Beck AT, Steer RA. Beck Anxiety Inventory Manual. San Antonio, TX: The Psychological Corporation Harcourt Brace and Company; 1993. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]