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Annals of Psychophysiology                                                                                                        Volume 3, October 2016                  
©Advance Educational Institute & Research Centre                                                                    www.aeirc-edu.com 

ISSN 2412 - 3188 
 

Original Article 

A Cross-Sectional Analysis Of  

Potential Stressors Leading to Depression Among Medical 

Students of Public Sector Universities of Sindh 
Aatir H. Rajput1, Muhammad Muneeb2, Tahir Hanif3, Abid Ali4, Anam Shaikh5, Uraza Noor6 & Usama Shaikh7 

Liaquat University Hospital  

LUMHS Research Forum 

Sir Cowasjee Jehangir Institute of Psychiatry 

Liaquat University of Medical & Health Sciences, Jamshoro 

Combined Military Hospital (C.M.H.), Hyderabad 

Corresponding email: aatirh.rajput@gmail.com 

 

Abstract 

Background: Till the 70's, it was believed that depression among students was rare or even non-existent. This 

concept has now begun to change. Research studies that show presence of depressive problems in students have 

started surfacing but much more need to be explored. Objective: To find out the causes and level of stress and 

depression among undergraduate medical students of public sector medical universities and medical colleges of 

Sindh. Methods: This cross sectional psycho-social analysis included 587 undergraduate medical students from 6 

public sector medical institutes of Sindh. Multistage sampling was implemented. Sampling procedure includes both 

stratified sampling and simple random sampling. Stratification was done on the basis of location of university and 

medical college and year of study. Informed consent was taken from every student. Stress and depression levels 

were measured in accordance to academic and non-academic stressors. Data analysis was done on SPSS version 

17.0. Results: Girls showed a much higher depression score in comparison with boys. Hostilities had a significantly 

greater depression score than those who were living with their families. It was revealed that students having higher 

grades and GPA had much higher scores of depression compared to students having lower grades and GPA. Fear of 

unemployment after studies and lack of positive response from parents and institution were few of the most potent 

stressors. Conclusion: On the basis of our result we conclude that a decrease in medical syllabus and time extension 

in semesters may directly reduce students’ workload and consequently decrease the depression level. Stress 

management programs should be conducted in every institute for coping with the stress.  Efficacious moral and 

substantial support from faculty, teachers and families is crucial to ameliorate of students’ health. 

 

Keywords 

Stress, Depression and medical students. 

 

Introduction 

Although there are many case studies on depression 

since the 17th century but scientific interest on 

depression among medical students is developed 

recently. The aim of medical education is to get 

knowledge, to be a highly skilled, competent and a 

professional physician who is equipped enough to 

care for the nation’s illness, who proceeds 

advancement in field of medicine, and public health. 

Depending on these particular characteristics, one 

may anticipate a medical institute would be a time of 

personal growth, demand, and a great source of stress 

and depression. Till the 70's, it was believed that 

depression among students was rare or even non-

existent (Maria A. et al, 2013; Besseghini VH, 1997). 

This concept has now begun to change. Research 

studies that proved presence of depressive 

problems in students have also suggested changes in 

this conception. Major depression (MD) in students is 

commonest, debilitating and recurrent type of 

depression that involves a high degree of morbidity 

and mortality and it is a great public health concern, 

although still often not diagnosed nor much treated. 

Several studies noticed the phenomenon of 

depression in students has been occurring more 

frequently and earlier than before. But there are some 

epidemiological studies about depression at this 

period of life (Maria A. et al, 2013; Mirza KAH. et 

al, 1996)  

 

Epidemiological studies about depression and 

depressive symptoms in students have shown 

differences of occurrence, in the different rates of the 

specific age groups and in the gender distribution. A 

rise in occurrence of depression and depressive 

symptoms during teenage has been accepted widely, 

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Aatir H. Rajput 50 

  

Annals of Psychophysiology                                                                                                        Volume 3, October 2016                  
©Advance Educational Institute & Research Centre                                                                    www.aeirc-edu.com 

ISSN 2412 - 3188 
 

but the exact time or age in which it happens is still 

not clearly known. It is also not found yet whether 

there are high chances of predominantly depressive 

symptoms associated with age and gender differences 

or not (Maria A. et al, 2013; Mirza KAH. et al, 

1996). 

 

Stress is usually defined as any unusual need of a 

body based on one’s internal or external resources 

that makes a person to utilize more energy reserves in 

excess of what would be necessary for dealing with 

ordinary life events. Signs of being stressed can be 

demonstrated through observable behaviors such as 

tremors or tics, thumb or finger sucking, nail biting, 

hair twirling, helplessness, physical hostility, 

complaints of physical aches and pains, irritability, 

nervous laughter, outbursts, crying, and withdrawal. 

Stress affects most people in some way. Acute stress 

causes rapidly change along whole body. Almost all 

biological systems of the body like circulatory 

system, immune system, respiratory, digestive 

system, sensory organs, and nervous system, are 

accelerated efficiently to cope with upcoming danger. 

Chronic stress can have serious effects on one’s 

health and it should be treated like any other health 

concern in order to get a sound physically and 

psychologically fit individual. (Roberts RE. et al, 

1995) 

 

Medical institutes demand more academic and 

clinical knowledge and to cope up with this, students’ 

working hours into nights and weekends, are much 

extended [1]. A number of sources of stress are 

frequent examinations, exam phobia, time limits, 

reduced leisure time, an over demanding curriculum, 

complicated treatments, possible conflicts with 

patients, fellow students, institution staff and faculty, 

lack of self-esteem, and most important the 

differences between the student’s expectations and 

reality. (Rajab L, 2001) 

 

Based on the current literature and scientific studies 

on depression and stress among students, I strongly 

consider that medical students among all have 

greatest risks of depression and depressive symptoms 

because of the increasing needs and challenges of the 

medical profession related to both quality and 

quantity of academic and clinical performance. This 

study proves that a change is strongly needed in 

curriculum planning and working environment of 

medical institutions. Academic as well as non- 

academic sources of stress should be minimized. 

Furthermore, effective communication and assistance 

from faculty, administration and families is essential 

in order to get better results from students. 

Methodology  

This cross sectional multi-center study was designed 

to get a complete picture of the prevalence of stress 

and depression among undergraduate medical 

students of public sector medical colleges and 

universities of Sindh, namely Dow Medical College, 

Karachi, Sindh Medical College, Karachi, Liaquat 

University Of Medical & Health Sciences, Jamshoro, 

Peoples University Of Medical & Health Sciences 

For Women Shaheed Benazirabad, Chandka Medical 

College, Larkana And Ghulam Mohammad Maher 

Medical College, Sukkur, and to find out the causes, 

perceptions and preventive measures for stress and 

depression. 587 undergraduate medical students both 

male and female took participation in the study. 

Multistage sampling was implemented and equal 

numbers of questionnaires were assigned to each 

public sector medical university or college of Sindh. 

Sampling procedure includes both stratified sampling 

and simple random sampling. Stratification was done 

on the basis of location of university and medical 

college (being public sector university is foremost 

decisive factor), and year of study. 20 questionnaires 

were assigned to each studying year and further 

sampling procedure was conducted according to 

simple random sampling. Every 17th student 

according to call roll number was selected for the 

study. A prerequisite informed consent was taken 

from every student.  A semi quantitative 

questionnaire based on Hamilton scale of depression 

for adults was designed, having full information of 

demographic bio data and information about financial 

status, place of residence (hostel or home) and life 

luxuries. Other questions were about duration of 

study in normal days and during exams, number of 

assignments and tests, number and types of 

recreational activities occurring in institutions and 

type of hobby and time given to it, were also asked 

from every participant. Data collection took three and 

half month, started from 10th of February, 2014 to 

26th of May, 2014 and Data processing and analysis 

was done by using SPSS version 17.0. Total duration 

of study was 6 months i.e. from 15th of January, 2014 

to 15th of June, 2014.  

 

Results 

A total of 600 questionnaires were administered to 

both male and female undergraduate medical students 

by using multistage sampling procedure (100 to each 

Public Sector University or medical college) out of 

which 587 (98%) questionnaires was returned. Out of 

which 64.05 % (376) were girls and 35.95 %( 211) 

were boys. Mean age was 20.13 while standard 

deviation was found to be of + 1.73. 

 

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Aatir H. Rajput 51 

  

Annals of Psychophysiology                                                                                                        Volume 3, October 2016                  
©Advance Educational Institute & Research Centre                                                                    www.aeirc-edu.com 

ISSN 2412 - 3188 
 

453 435
376

478

409

545

134 152
211

79

178

42

Less time for

preparataion for

exams

Lack of time for

assignments

Fear of

unemployment

after study

Fear of parents

after failure

Lack of positive

response from

parents &

teachers

Lack of

recreational

activities

Main Stressors

Yes

No

64.05

39.95

Gender Distribution Among Medical Students

Girls Boys

 

As in general, girls showed much higher depression 

score (22.76) in comparison with boys (20.34). 

Combine depression score of all undergraduate 

medical students was 21.67. Hostilities had 

significant depression score i.e. 21.35 than those who 

were living with their families i.e. 19.28.  

 

Massive syllabus, day to day assignments, weekly 

and monthly tests and lack of recreational activities 

among students had highly overburdened them. It can 

be assumed by the study that students having higher 

grades and GPA had much higher scores of 

depression compared to students having lower grades 

and GPA. The divergence in observed problems 

among public sector medical colleges and 

universities of Sindh were investigated.  

Trouble in getting good study material, poor time 

management and fear of parents in case of being 

failed, were reported as main stressors by the 

students. Fear of unemployment after studies and 

lack of positive response from parents and institution 

had significantly raised stress and depression among 

students. 

 

 

 

 

 

 

 

 

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Aatir H. Rajput 52 

  

Annals of Psychophysiology                                                                                                        Volume 3, October 2016                  
©Advance Educational Institute & Research Centre                                                                    www.aeirc-edu.com 

ISSN 2412 - 3188 
 

534

173

473

508

53

214

114

79

Vast syllabus

Language difficulty

Unsuitable semester length

Difficulty in time management

Students Complaints

No

Yes

21.67

20.34

22.76

21.35

19.28

Overall Score Boys Girls Hostilite Day Scholars

Mean Depression Score

 

 

Discussion  

Studies revealed that unskilled students have always 

been vulnerable to many stressful situations in their 

life, especially in pursuing of their professional 

education in much competitive environment. 

Students suffered from depression at least once or 

more during the course of their professional 

education. Being most needy, challenging and 

stressful learning places (Polychronopoulos A. et al, 

2005) medical institutions are greatly renowned.  

Studies suggested that a considerable portion of 

medical students’ i.e.15-26% had been suffering from 

one or other kind of emotional disturbance and they 

were seriously in need of prompt treatment (Jenny F, 

1986; Pitts FN. et al, 1961). It is evident that the 

duration of stress is of much worth and there is a 

decrease in stress with advancing year of medical 

training (Adsett CA, 1968).  

 

Spotting out of significant problems is of much 

importance in medical programs as it may give 

students and faculty an opportunity to take preventive 

measures for stress (Yap. et al, 1996). This can be 

proven by the fact that majority of medical students 

are not well adopted to the educational environment 

and to the workload imposed by the medical 

institution which leads to higher levels of stress and 

depression (Bradley I. et al, 1989). Higher levels of 

psychiatric illness in medical students were found 

during a study in US when compared with general 

population. More than 20% of medical students met 

diagnostic criteria for psychiatric illness (Lloyd C. et 

al, 1984). A number of studies have demonstrated the 

relation between stress concept in regards or several 

factors like gender, marital status, professional 

courses, academic year, living environment, and 

socio-cultural factors that affects student’s mental 

health (Polychronopoulos A. et al, 2005; Yap A. et al, 

1996; Tedesco LA, 1986; Tedesco LA. et al, 1987; 

Grandy T. et al, 1989; Westerman G. et al, 1993; 

Heath JR. et al, 1999). 

 

Studies also suggest a higher prevalence rate of 

depression in women than in men. (Adsett CA, 1968; 

Yap. et al, 1996; Bradley I. et al, 1989; Lloyd C. et 

al, 1984; Tedesco LA, 1986; Tedesco LA. et al, 1987; 

Grandy T. et al, 1989; Westerman G. et al, 1993; 

Heath JR. et al, 1999). Although there are not much 

studies that shows discrimination factor among male 

and female students but the fact that female doctors 

who are doing postgraduate training have noticeably 

higher rates of mental health problem than male 

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Aatir H. Rajput 53 

  

Annals of Psychophysiology                                                                                                        Volume 3, October 2016                  
©Advance Educational Institute & Research Centre                                                                    www.aeirc-edu.com 

ISSN 2412 - 3188 
 

doctors is revealed by some researchers. (Borrill CS. 

et al, 1996) 

Modern educational systems have been a cause of 

increase prevalence of stress, anxiety and depression 

among medical students, suggested by a number of 

studies (Ball S. et al, 2002; Tyssen R. et al, 2001). 

Furthermore it is also evident that mental distress 

among doctors in practice (Gelfand DV. et al, 2004) 

has its roots somewhere in medical school (Tedesco 

LA. et al, 1986). It is also suggested that the practice 

of medicine either by qualified physicians (Vincent 

MO, 1983) or medical students (Pitts FN. et al, 1961) 

produces risks to mental health and the link between 

medical training and mental health problems have 

also been suggested (Reibord SP, 1983). Majority of 

research presented seconds the presence of a relation 

among stress and depressive episodes, based on 

sporadic stress causing agents that have an annoying 

and unwanted content. Generally, these agents affect 

both psychological and physical health of student but 

some studies also suggest the direct effects of these 

agents that create hazardous-stress-harmful pathway.  

 

An epidemiological study stated that non respondents 

to questionnaires were supposed to be more 

depressed than respondents (Vernon SW. et al, 1984) 

but the response rate of my study (98%) in 

comparison with previous studies particularly makes 

its finding worth important and it can be applicable to 

all medical students. A total of 687 undergraduate 

medical students belonging 7 public sector medical 

institutions of Sindh have been surveyed in this study 

which shows the differences in observed problems 

and hence their stress and depression level. Students 

coming from Cambridge level system (had studied in 

‘A’ levels) showed much less academic and clinical 

problems in comparison with the students coming 

from higher secondary college system (intermediate 

system).  

 

It is found that students having low grades and GPA 

have statistically significant greater number observed 

problems than that of students with high grades and 

GPA in overall depression score. This is rational to 

results of other studies which similarly showed same 

results that low satisfaction rate of students with their 

educational environment characteristically causes 

low academic achievements (Mayya SS et al, 2004). 

Fear of talking to patients, improper handling and 

consoling and following up of proper treatment was a 

major source of stress as reported by most of 

students. Clinical practice being most valued one has 

undoubtedly as its leading role in developing stress 

and depression in students. Monthly tests and 

assignments have also significant role in shattering of 

mental health of students.  

 

Third most reported cause of depression is the 

communication and coordination gap between 

students and faculty. Students living at hostel have 

less depression rate as compared to those living with 

families. High depression score for student- faculty 

relationship and clinical training is typically found in 

students living with their families. The probable 

causes of which are increasing demands of social 

activities that overburdened student and limit time as 

well.  Students those who are disgraced by the 

teachers in front of their class fellows tend to show 

more depressive symptoms. Feeling of frustration and 

powerlessness was rate highest on stress incident 

record while tension and anxiety- surprisingly were 

on second grade. These feeling may become an 

imminent part of medical students’ nature and they 

significantly contribute to experience of the ‘learned 

helplessness’ that is eventually associated with 

depression. (Jenny F, 1986; Mayya SS et al, 2004). 

 

Medical institutions are becoming more demanding: 

academic and clinical training now require more 

working hours. Examination fear, day to day tests 

and assignments, short preparation leaves, strenuous 

curricula, clinical training, anxious and conflicted 

patients, complicated treatment, difficult procedures 

and follow-ups, fellow colleagues, staff and faculty, 

lack of recreational activities and lack of self-

confidence and self-esteem are typical sources of 

stress for medical students. With Proper counseling 

(Mc Auliffe WE. et al, 1984) and support from 

teachers (Jenny F, 1986; Filed D, 1984) a marked 

reduction in depression levels among medical 

students can be made possible which will surely 

result in more, better and efficacious output by 

medical students and in broad sense it will ultimately 

be the society that will have maximum benefits. 

 

Conclusion 

Strenuous and limitless syllabus of medical 

profession was found to be the major source of 

depression. Conventional methods of teaching, 

clinical training, fear of patients and lack of student-

faculty relationship were important unanswered 

matters. A lessen in medical syllabus, a bit time 

extension in semester may directly reduce students’ 

workload and indirectly reduces the depression level. 

It is a recommendation that by up gradation and 

modification of clinical training system may 

contribute significant reduction in observed problems 

of students. This study confirms the fact that needs of 

medical profession related to both quality and 

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Aatir H. Rajput 54 

  

Annals of Psychophysiology                                                                                                        Volume 3, October 2016                  
©Advance Educational Institute & Research Centre                                                                    www.aeirc-edu.com 

ISSN 2412 - 3188 
 

quantity of academic and clinical practice are 

important sources of stress.  

The sources of stress both academic and clinical must 

be considered in planning of curricula. Working 

environment, student-faculty relationship and 

syllabus length should be upgraded and modified for 

betterment of students’ mental health. Stress 

management programs should be conducted in every 

institute for coping with the stress. In the last but not 

the least efficacious moral and substantial support 

from faculty, teachers and families is crucial for 

amelioration of students’ health. 

 

Conflict of interest 

All the authors disclosed that there is no conflict of 

interest associated in the preparation of this article. 

 

Acknowledgements 

We would like to acknowledge the intellectual 

assistance and technical support provided by 

LUMHS Research Forum 

 

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