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ORIGINAL ARTICLE
Year : 2018  |  Volume : 16  |  Issue : 1  |  Page : 26-29

Depression, anxiety, and stress among undergraduate dental students in Hyderabad City, Telangana, India: A cross-sectional study


1 Department of Public Health Dentistry, Panineeya Institute of Dental Sciences and Research Centre, Master of Dental Surgery, Hyderabad, Telangana, India
2 Department of Public Health Dentistry, Panineeya Institute of Dental Sciences and Research Centre, Master in Public Health, Hyderabad, Telangana, India

Date of Submission07-Feb-2017
Date of Acceptance11-Jan-2018
Date of Web Publication23-Mar-2018

Correspondence Address:
Dr. Ambati Sravani
Department of Public Health Dentistry, Panineeya Institute of Dental Sciences and Research Centre, Road No 5, Kamala Nagar, Dilsukhnagar, Hyderabad - 500 060, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaphd.jiaphd_10_17

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  Abstract 

Introduction: Increased levels of psychological disturbances such as depression, anxiety, and stress (DAS) among dental students affect the way these students take care of patients. Aim: The aim of this study is to assess DAS among undergraduate dental students in Hyderabad city, Telangana, India. Materials and Methods: A short version of depression, anxiety, and stress scale was distributed to undergraduate dental students in four dental colleges. Comparison among the variables was done using ANOVA and Independent t-test. Results: The study group comprised 200 (23.7%) males and 645 (76.3%) females. The overall mean DAS score and its dimensions were not significant based on gender. Married students showed significantly more DAS compared to unmarried (P < 0.05). When the year of study was considered for all colleges together, the overall mean DAS score and its individual dimensions score were significantly high among III year students followed by IV, I, and II years (P < 0.05). Conclusion: Clinical years were more stressful than the nonclinical years. This suggests a need for special attention to the structure of the clinical program, particularly at the point of transition from the preclinical to the clinical phase.

Keywords: Anxiety, dental, depression, students


How to cite this article:
Sravani A, Doshi D, Kulkarni S, Reddy P, Reddy S. Depression, anxiety, and stress among undergraduate dental students in Hyderabad City, Telangana, India: A cross-sectional study. J Indian Assoc Public Health Dent 2018;16:26-9

How to cite this URL:
Sravani A, Doshi D, Kulkarni S, Reddy P, Reddy S. Depression, anxiety, and stress among undergraduate dental students in Hyderabad City, Telangana, India: A cross-sectional study. J Indian Assoc Public Health Dent [serial online] 2018 [cited 2020 Feb 24];16:26-9. Available from: http://www.jiaphd.org/text.asp?2018/16/1/26/228291


  Introduction Top


Depression, anxiety, and stress (DAS) have been recognized by the World Health Organization as important mental health disorders. Among the global burden of diseases, they are the fourth leading contributors and it has been projected that by 2020, they will become the second leading contributors after the cardiovascular-related diseases.[1]

Depression is a common mental disorder that presents with depressed mood, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy, and poor concentration.[2] Hence, depression is associated with a constellation of psychological, behavioral, and physical symptoms. Anxiety is a psychological disorder that is associated with significant suffering and impairment in functioning. It is a blend of thoughts and feelings characterized by a sense of uncontrollability and unpredictability over potentially aversive life events.[3] Stress, on the other hand, is a consequence of or a general response to an action or situation that places special physical or psychological demands, or both on a person. As such, stress involves an interaction of the person with the environment.[4]

In general, everyone experiences these mental health disorders; however, students are at the higher risk due to the transitional nature of student's life. They need to adjust themselves with life environment which requires compliance with new social norms and new friendship. Moreover, the increasing demand to perform well academically may contribute to increasing levels of DAS. Elevated levels of DAS among students may predispose them to physical and mental illness, substance misuse, absenteeism, diminished work efficiency, and burnout, thereby adversely affecting their academic performance.[5]

Medical and dental schools are known to be highly demanding and stressful learning environments. Dental education is regarded as a complex, demanding, and often stressful pedagogical exposure involving an acquisition of required academic, clinical and interpersonal skills during the course of learning.[6] According to Schmitter et al., stress encountered during dental education is more pronounced than during medical education.[7]

Extraordinary pressures, including a heavy schedule and the need to learn a large amount of information in a relatively short time, are responsible for depressive symptoms among dental students.[8] Anxiety levels among dental students are usually associated with fear of getting wrong diagnoses, hurting patients, dealing with medical emergencies, and getting infected.[9] Major stressor for all the dental students was examination and grades and fear of facing parents after failure followed by full working day, receiving criticism from supervisors about academic or clinical work, amount of cheating in dental faculty, rules, and regulations of the faculty and fear of unemployment after graduation.[10],[11] Six categories of potential stressors for dental students are academic performance, faculty relations, patient and clinic responsibilities, personal life issues, professional identity, and financial obligations.[12] Other causes of mental health disorders are change in sleeping habits, vacations/breaks, change in eating habits, an increased workload, and new responsibilities. Overall, the highest ranked sources for these mental health disorders reported for dental students were examinations, fear of failing or falling behind, and completing course requirements.[7]

Studies on DAS among dental students conducted in several different countries report generally consistent findings.[5],[13],[14] Retrieving knowledge about psychiatric morbidity is important as it can help in implementing preventive mental health programs among students. Hence, the present study aimed to assess the DAS among undergraduate dental students in Hyderabad city using depression, anxiety, and stress scale (DASS-21). The objectives of the study were to determine and to compare the depression DAS based on gender, marital status and year of study.


  Materials and Methods Top


A cross-sectional questionnaire survey was conducted among undergraduate dental students in Hyderabad city, Telangana, India, for a period of 3 months from December 2015 to February 2016. A pilot study was conducted on 30 students to find out the feasibility of the study and for sample size estimation. When mean is the parameter of the study

, where

n = required sample size

Z = Standard normal variate value (Z-standard value = 1.96)

S = Standard deviation of DASS (0.63)

d = margin of error at 5% (standard value = 0.05)

With a confidence level of 95% and sampling error at 5%, the estimated sample size obtained was minimum of 610 participants. List of dental colleges in Hyderabad city was obtained from the NTR University Health Sciences official website. Permission to carry out the study was obtained from the principals of respective dental colleges and those who gave permission to conduct the study were included in this study.

The approval and consent for this study was obtained from the Institutional Review Board. The study was conducted in full accordance with the World Medical Association Declaration of Helsinki. Verbal consent was obtained from each participant.

A self-administered DASS-21[15] was distributed to undergraduate dental students (excluding Interns) during lecture hours in the classroom. The details obtained from the students included age (in years), gender (male/female), marital status (married/unmarried), year of study (I/II/III/IV), and college.

DASS-21[15] is a 21-item short version synthesized from the original 42-item survey. This prevalidated questionnaire has seven items for each of the three scales designed to measure the negative emotional states of DAS. Items 3, 5, 10, 13, 16, 17, and 21 form the Depression scale; items 2, 4, 7, 9, 15, 19, and 20 forms the anxiety scale and items 1, 6, 8, 11, 12, 14, and 18 are included in the stress scale. A four-point severity/frequency scale was used to rate the extent to which the respondents had experienced each symptom over the past week from “never” (0) to “most of the time” (4). The sum of the scores obtained was multiplied by 2 and then evaluated as per the severity-rating index.

Data were entered and analyzed using the Statistical Package for Social Sciences Software (Statistical data 2003 SPSS, Inc., an IBM company, Chicago, Illinosis, USA version 12.0). One way analysis of variance (ANOVA), Post-hoc analysis, and Independent t-test was used for comparison among the variables. Correlation among the three variables of DAS was calculated by Karl Pearson correlation coefficient, and the internal consistency (reliability) for the DASS was measured using Cronbach's alpha. Differences were tested at a significance level of P < 0.05.


  Results Top


Out of 980 questionnaires distributed, 845 undergraduate dental students completed questionnaire yielding a response rate of 80.2%. The study group comprised 200 (23.7%) males and 645 (76.3%) females with a mean age of 23.2 ± 2.1 years. Majority of the students were unmarried (96.8%). Based on the year of undergraduate study, 31.8% of students were in I year, 18.3% in II year, 22.7% in III year, and 27.1% in IV year [Table 1].
Table 1: Demographic distribution of the study population

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Mean DAS score among the study group was found to be 36.9 ± 1.5, and its individual dimensional scores were 11.9 ± 4.1, 12.2 ± 4.0, and 12.9 ± 4.3 for DAS, respectively. Based on gender, the overall mean DAS score and its dimensions were not significant. However, marital status had a significant difference, where in married students showed more DAS compared to unmarried students (P< 0.05). When the year of study was considered for all colleges together, the overall mean DAS score and its individual dimensions score were significantly high among III year students followed by IV, I, and II year (P< 0.05). This on further post-hoc analysis revealed that for overall DAS score, III year had significantly higher score as compared to other years; but individual dimension comparison revealed only stress being significant among III and I year students (P< 0.05) [Table 2].
Table 2: Comparison of mean Depression Anxiety and Stress Scale and its dimensions based on gender, marital status, year of the undergraduate study and colleges

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Correlation among the dimensions of the DAS scale revealed that DAS was significantly positively correlated with each other [Table 3].
Table 3: Correlation among three variables by Karl Pearson's correlation coefficient

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  Discussion Top


It has been reported that dental students express considerable stress symptoms during their training and that they are more anxious than the general population, showing higher levels of depression, obsessive-compulsive disorders, and interpersonal sensitivity than age-matched norms.[14] Thus, recognizing the importance of mental health, the present study was carried out to assess the DAS among undergraduate dental students in Hyderabad city using DASS-21.

The DASS [15] is the only self-report scale which measures all the three negative emotional states, i.e., depression, anxiety, and stress altogether and is designed to maximize discrimination between the three components it measures. The DASS has high reliability and a factor structure that is consistent with the allocation of the items to subscales, exhibiting high convergent validity with other measures of anxiety and depression in both clinical and community samples.[13],[15] In the current study, we have used DASS-21 which is a short form of the DASS-42 and has a number of advantages over the full-length version. First, and most obviously, it takes less time to complete. Second, the items retained from the full-length version are generally superior to those omitted and as a result, has a cleaner factor structure. Furthermore, it has been revealed that the short form of DAS is more consistent compared to full-scale version.[13],[15] In India, there has been an increase in the number of women taking up dentistry.[16] This has been identified in the present study as well where in 76.3% of the study participants were females. In our study, the overall mean DAS score and its dimensions between male and female students were not statistically significant. This is in agreement with the findings reported by Bradely et al.[17] and Heath,[5] but in contrast with studies done by Alzahem et al.[18] and Madhan et al.[19] wherein they reported female students to have more DAS levels.

When marital status was considered, married students showed more symptoms of all the three negative emotional states, i.e., DAS than their unmarried colleagues. This could be due to increased responsibilities wherein the students have to simultaneously balance their personal and professional life. Conversely, in a study by Madhan et al.,[19] more symptoms were observed in unmarried students.

In this study, when academic years of all the four colleges together were considered, the overall DAS score was higher among III Year students. This can be due to the fact that in this year of study students are introduced to clinical training involving patients for the first time and need to concentrate on both dental and medical subjects. In addition, they are required to directly deal with patients and have to complete certain clinical requirements. Patient being late or not showing up for their appointment may contribute to increase in the stress. Our findings are in agreement with previous studies,[14],[20] which suggest that clinical years are more stressful than the nonclinical years. On the other hand, findings reported by Westerman et al.[13] showed that the nonclinical years (I and II) were more stressful.

The present study has to be generalized with a limitation such as the self reporting and close-ended nature of the questionnaire since there is no interviewer to intervene in the case of any misunderstanding in the communication exchange between the researcher and the respondent. Close-ended questions limit the respondent to the set of alternatives being offered.


  Conclusion Top


The present study reports high prevalence of DAS among this group of undergraduate dental students. While the first two (preclinical) years have less prevalence, dental students in the clinical years have more. This suggests a need for special attention to the structure of the clinical program, particularly at the point of transition from the preclinical to the clinical phase. Moreover, the highest perceived sources of DAS reported by students should be further investigated and methods to minimize them should be developed and implemented. A congenial environment needs to be created in the dental schools so that students can pursue their studies with less anxiety or stress. Strategies for stress prevention and management should be implemented in dental schools to improve students' well-being, prevent drop out, and ensure proper patient care.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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World Health Organization. Mental Health: Depression. Available from: http://www.int/mentalhealth/management/depression/definition/inindex.html. [Last retrieved on 2010 Aug 28].  Back to cited text no. 1
    
2.
Marcus M, Yasamy MT, Van Ommeren M, Chisholm D, Saxena S. Depression: A Global Public Health Concern. Vol. 1. WHO Department of Mental Health and Substance Abuse; 2012. p. 6-8.  Back to cited text no. 2
    
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Md Yasin AS, Dzulkifli MA. Differences in psychological problems between low and high achieving students. J Behavior Sci 2009;4:60-71.  Back to cited text no. 3
    
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Ghaderi AR, Kumar V, Kumar S. Depression, anxiety and stress among the Indian and Iranian students. J Indian Acad Appl Psychol 2009;35:33-7.  Back to cited text no. 4
    
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Heath JR, Macfarlane TV, Umar MS. Perceived sources of stress in dental students. Dent Update 1999;26:94-8, 100.  Back to cited text no. 5
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7.
Schmitter M, Liedl M, Beck J, Rammelsberg P. Chronic stress in medical and dental education. Med Teach 2008;30:97-9.  Back to cited text no. 7
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Kumar S, Dagli RJ, Mathur A, Jain M, Prabu D, Kulkarni S, et al. Perceived sources of stress amongst Indian dental students. Eur J Dent Educ 2009;13:39-45.  Back to cited text no. 11
    
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Westerman GH, Grandy TG, Ocanto RA, Erskine CG. Perceived sources of stress in the dental school environment. J Dent Educ 1993;57:225-31.  Back to cited text no. 13
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Lovibond SH, Lovibond PF. Manual for the Depression Anxiety Stress Scales. 2nd ed. Sydney: Psychology Foundation; 1995.  Back to cited text no. 15
    
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Pani SC, Al Askar AM, Al Mohrij SI, Al Ohali TA. Evaluation of stress in final-year Saudi dental students using salivary cortisol as a biomarker. J Dent Educ 2011;75:377-84.  Back to cited text no. 16
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Bradely IF, Clark DC, Eisner JE, De Gruchyy K, Singer DL, Hinkleman K, et al. The student survey of problems in the academic environment in Canadian dental faculties. J Dent Educ 1993;57:225-31.  Back to cited text no. 17
    
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Alzahem AM, van der Molen HT, Alaujan AH, Schmidt HG, Zamakhshary MH. Stress amongst dental students: A systematic review. Eur J Dent Educ 2011;15:8-18.  Back to cited text no. 18
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