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Mental health and burnout in Nepalese medical students: an observational study

Abstract

Background

Mental health problems among medical students are highly prevalent internationally. There have been very few studies however in Nepal. This study aimed to assess the frequency of mental health problems and burnout in Nepalese medical students.

Results

A total of 169 students responded to the questionnaire. Half (50%) of the surveyed students had some form of mental health problem according to the GHQ-12, while the OLBI showed that 85% students were disengaged and 65% were exhausted. The CAGE screening tool was positive in 14%, and 11% described illicit drug use. Sixty-four percent of students identified their academic studies as their major source of stress.

Conclusions

Timely recognition of mental health problems is imperative to avert psychiatric illness. Training on early identification and management of stress would be helpful. Further studies are required to identify the factors associated with poor mental health.

Background

Research worldwide has demonstrated a higher frequency of mild mental health disease and worse quality of life among medical students, when paralleled with an age-matched population [1,2,3,4,5,6,7].

Medical students are exposed to multiple stressors that may detrimentally affect their mental health, such as study, difficult academic environments, heavy workload, sleeplessness, and exposure to serious illness. They are also exposed to substantial tuition fees incurring financial difficulties, constant travel raising housing concerns, and/or a lack of recreational activities [8, 9]. These issues may result in significant anxiety or mood disorders, compromise academic attainment, and heighten the risk of medical errors, dropout, alcohol and substance abuse, and tragically in some cases suicide [10,11,12]. Interestingly, these problems are also seen to mature and endure among junior doctors [13, 14].

Studies have shown that medical students and doctors are highly prone to burnout. Burnout refers to a psychological syndrome distinguished by overwhelming exhaustion, depersonalization, and a decline in one’s productivity [15]. This in turn can lead to such things as poor patient care, increases in medical errors, suicidal ideation, and substance misuse [16,17,18].

There is minimal information in the literature regarding psychological distress in Nepalese medical students and trainee doctors. In Nepal, a number of studies have previously been published assessing the burden of anxiety and mood disorders within the medical student population. These studies demonstrated a high burden of anxiety and depression, with a prevalence of 35–45% and 29–31%, respectively [3, 19,20,21]. The aim of this study was to further ascertain the prevalence of mild mental health problems, burnout, and stressors in Nepalese medical pupils.

Methods

Our study used an online survey on the Typeform platform. This ensured anonymity for participants. Students from Nepal took part alongside students from many countries and were invited by an array of methods in medical schools and on social media. Information collected included demographic data such as year of study, age, gender, and highest educational level achieved by the parents. Previous mental health issues prior to medical school entry such as diagnosis of a mental health condition, use of psychiatric medication, and current mental health issues were explored. The consumption of alcohol and/or drugs and burnout were measured using the CAGE questionnaire and the OLBI respectively.

The Oldenburg Burnout Inventory (OLBI) [22] is a reliable and valid burnout inventory that has been well used over time and in different groups. It aims to measure two main factors, namely exhaustion and disengagement, through the use of sixteen questions that are ranked based on level of agreement. A respondent’s total burnout score places the individual in categories ranging from very low to very high risk of burnout. The General Health Questionnaire (GHQ-12) [23] and the CAGE questionnaire [24] were included to detect minor psychological problems and alcohol and substance-related problems among students. Data was collected and stored in Excel spreadsheets and analyzed to provide means or percentages with standard deviations (SD) or 95% confidence intervals (CI).

Results

One hundred sixty-nine medical students from two Nepalese universities responded. Table 1 represents the demographics data obtained from this sample. Females accounted for 50% of the respondents. Out of those who participated, 17% were in their 1st year of study, 11% in the 2nd year, 24% in the 3rd year, 14% in the 4th year, 17% in the 5th year, and 18% were post graduate students. Most students indicated high academic achievement within their family, with 65% specifically indicating that their parents held a graduate degree. Eighty percent of students did not take up any other part-time or full-time employment in conjunction with their medical studies.

Table 1 The sociodemographic characteristics of the Nepalese respondents

Prior to joining medical school, 4% of students had been diagnosed with a mental health condition. This increased to 8% within medical school. Sixty-four percent of students indicated that their academic studies represented their leading source of stress. The CAGE test showed that 14% were screened positive for problem drinking and potential alcohol problems. Twenty-three students (14%) described taking medications to enhance concentration or feel better, while 11% of students reported the use of recreational drugs. Table 2 provides a summary of these issues.

Table 2 Health characteristics of our respondents

Half of the respondents (50%) scored above threshold on the GHQ-12, indicating some mental health problems. The mean score on the GHQ 12 was 3.5. The mean score on the OLBI (for burnout syndrome) was 2.5. Disengagement was identified in 85% of students and exhaustion in 65% (Table 3).

Table 3 GHQ and OLBI positivity

Discussion

Our study has provided additional data concerning the mental wellbeing of Nepalese medical students. The prevalence of mental health problems using the GHQ-12 in our study was found to be 50%. Studies from Nepal have previously reported a prevalence of anxiety ranging from 32 to 45% and of depression from 29 to 31% among medical students [3, 19, 20]. Our findings are comparable with similar recent studies internationally [6, 7, 25, 26], including a systematic review among medical students in Asia that reported 53% of medical students as being vulnerable to mental health issues [27].

Rates of burnout were very high. Nine out of ten respondents were disengaged and seven out of ten were exhausted. Another Nepalese study showed almost 50% of medical students had burnout syndrome [3]. In a Moroccan study, 90% were exhausted and 70% were disengaged (6) whereas 90% of medical students were at risk of burnout in a UK study [4]. Disengagement and exhaustion scores, however, were lower among Italian students [26]. These results might be due to differences in socio-economic status, educational environment, different levels of competition, and/or different levels of familial support. Burnout and mental health problems were more prevalent in female than male students and this result is similar to previous studies [7]. This may be the result of underreporting of symptoms by men, compared to the female gender [28]. Depression seen in female medical students has been found to be linked with personality traits [29], gender inequality, and stigma [30]. In addition, 64% of our students reported that their academic studies were the leading cause for their stress. This is also in keeping with other published data globally [3, 6, 31].

Nine percent of students had reported a recent or current diagnosis of mental illness, while only 4% had psychiatric diagnosis prior to starting university. This rate seems to be lower than in the UK, where 27% of respondents have been diagnosed with mental illness at some point in their life, with 7% stating that this diagnosis was made in the past year [4].

Problem drinking was reported by 14% of students. Eleven percent reported illicit drug use, among which 9% had used cannabis. Similar findings are found in other Nepalese studies where 15% students had used cannabis during medical studies. Previous studies in Nepal have reported a similar distribution of alcohol and cannabis abuse, which is aided by the relatively easy availability of cannabis [32].

Conclusions

Our study found that mental health problems are high among Nepalese medical students. Failure to identify these problems leads to increased psychological illness with undesirable effects throughout careers and lives. This study will help stakeholders, including local policy makers, to make further strategic plans to alleviate the mental health problems of students. These strategies could include training for the early identification of stress and its management and making the academic curriculum more “student friendly.” Further reaserch is needed to delineate and categorize the factors associated with psychological distress in medical students globally, in order to appropriately inform policy at local, national, and international levels.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

GHQ:

General Health Questionnaire

OLBI:

Oldenburg Burnout Inventory

ADHD:

Attention deficit hyperactive disorder

ASD:

Autism spectrum disorder

References

  1. Kumar GS, Jain A, Hegde S (2012) Prevalence of depression and its associated factors using Beck Depression Inventory among students of a medical college in Karnataka. Indian J Psychiatry. 54(3):223–226. https://doi.org/10.4103/0019-5545.102412

    Article  PubMed  PubMed Central  Google Scholar 

  2. Dyrbye LN, Thomas MR, Shanafelt TD (2006) Systematic review of depression, anxiety, and other indicators of psychological distress among US and Canadian medical students. Acad Med. 81(4):354–373. https://doi.org/10.1097/00001888-200604000-00009

    Article  PubMed  Google Scholar 

  3. Pokhrel NB, Khadayat R, Tulachan P (2020) Depression, anxiety, and burnout among medical students and residents of a medical school in Nepal: a cross-sectional study

    Google Scholar 

  4. Bhugra D, Sauerteig S-O, Bland D, Lloyd-Kendall A, Wijesuriya J, Singh G, Kochhar A, Molodynski A, Ventriglio A (2019) A descriptive study of mental health and wellbeing of doctors and medical students in the UK. Int Rev Psychiatry. 31(7-8):563–568. https://doi.org/10.1080/09540261.2019.1648621

    Article  PubMed  Google Scholar 

  5. Wege N, Muth T, Li J, Angerer P (2016) Mental health among currently enrolled medical students in Germany. Public Health. 132:92–100. https://doi.org/10.1016/j.puhe.2015.12.014

    Article  CAS  PubMed  Google Scholar 

  6. Lemtiri Chelieh M, Kadhum M, Lewis T, Molodynski A, Abouqal R, Belayachi J, Bhugra D (2019) Mental health and wellbeing among Moroccan medical students: a descriptive study. International Review of Psychiatry. 31(7-8):608–612. https://doi.org/10.1080/09540261.2019.1675276

    Article  PubMed  Google Scholar 

  7. Jafari N, Loghmani A, Montazeri A (2012) Mental health of medical students in different levels of training. Int J Prev Med. 3(Suppl1):S107

    PubMed  PubMed Central  Google Scholar 

  8. Dyrbye LN, Thomas MR, Shanafelt TD (2005) Medical student distress: causes, consequences, and proposed solutions. InMayo Clinic Proceedings 80(12):1613–1622. Elsevier. https://doi.org/10.4065/80.12.1613

  9. Levey RE (2001) Sources of stress for residents and recommendations for programs to assist them. Acad Med. 76(2):142–150. https://doi.org/10.1097/00001888-200102000-00010

    Article  CAS  PubMed  Google Scholar 

  10. Stewart SM, Lam T, Betson C, Wong C, Wong A (1999) A prospective analysis of stress and academic performance in the first two years of medical school. Med Educ. 33(4):243–250. https://doi.org/10.1046/j.1365-2923.1999.00294.x

    Article  CAS  PubMed  Google Scholar 

  11. Tyssen R, Vaglum P, Grønvold NT, Ekeberg Ø (2001) Suicidal ideation among medical students and young physicians: a nationwide and prospective study of prevalence and predictors. J Affect Disord. 64(1):69–79. https://doi.org/10.1016/S0165-0327(00)00205-6

    Article  CAS  PubMed  Google Scholar 

  12. Mandal A, Ghosh A, Sengupta G, Bera T, Das N, Mukherjee S (2012) Factors affecting the performance of undergraduate medical students: a perspective. Indian J Community Med 37(2):126–129. https://doi.org/10.4103/0970-0218.96104

    Article  PubMed  PubMed Central  Google Scholar 

  13. Firth-Cozens J (1987) Emotional distress in junior house officers. Br Med J (Clin Res Ed). 295(6597):533–536. https://doi.org/10.1136/bmj.295.6597.533

    Article  CAS  Google Scholar 

  14. Aktekin M, Karaman T, Senol YY, Erdem S, Erengin H, Akaydin M (2001) Anxiety, depression and stressful life events among medical students: a prospective study in Antalya, Turkey. Med Educ 35(1):12–17. https://doi.org/10.1046/j.1365-2923.2001.00726.x

    Article  CAS  PubMed  Google Scholar 

  15. Maslach C, Leiter MP (2016) Understanding the burnout experience: recent research and its implications for psychiatry. World Psychiatry. 15(2):103–111. https://doi.org/10.1002/wps.20311

    Article  PubMed  PubMed Central  Google Scholar 

  16. Shanafelt TD, Bradley KA, Wipf JE, Back AL (2002) Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 136(5):358–367. https://doi.org/10.7326/0003-4819-136-5-200203050-00008

    Article  PubMed  Google Scholar 

  17. Dyrbye LN, Thomas MR, Massie FS, Power DV, Eacker A, Harper W, Durning S, Moutier C, Szydlo DW, Novotny PJ, Sloan JA, Shanafelt TD (2008) Burnout and suicidal ideation among US medical students. Ann Intern Med. 149(5):334–341. https://doi.org/10.7326/0003-4819-149-5-200809020-00008

    Article  PubMed  Google Scholar 

  18. Kumar S (2016) Burnout and doctors: prevalence, prevention and intervention. InHealthcare. Multidisciplinary Digital Publishing Institute 4(3):37. https://doi.org/10.3390/healthcare4030037

  19. Adhikari A, Dutta A, Sapkota S, Chapagain A, Aryal A, Pradhan A (2017) Prevalence of poor mental health among medical students in Nepal: a cross-sectional study. BMC Med Educ. 17(1):1–7

    Article  Google Scholar 

  20. Kunwar D, Risal A, Koirala S (2016) Study of depression, anxiety and stress among the medical students in two medical colleges of Nepal. Kathmandu Univ Med J. 53(1):22–26

    Google Scholar 

  21. Basnet B, Jaiswal M, Adhikari B, Shyangwa P (2012) Depression among undergraduate medical students. Kathmandu Univ Med J. 10(3):56–59

    Article  CAS  Google Scholar 

  22. Halbesleben JR, Demerouti E (2005) The construct validity of an alternative measure of burnout: Investigating the English translation of the Oldenburg Burnout Inventory. Work Stress. 19(3):208–220. https://doi.org/10.1080/02678370500340728

    Article  Google Scholar 

  23. Zulkefly NS, Baharudin R (2010) Using the 12-item General Health Questionnaire (GHQ-12) to assess the psychological health of Malaysian college students. Global J Health Sci. 2(1):73

    Article  Google Scholar 

  24. Ewing JA (1984) Detecting alcoholism: the CAGE questionnaire. JAMA. 252(14):1905–1907. https://doi.org/10.1001/jama.1984.03350140051025

    Article  CAS  PubMed  Google Scholar 

  25. Strous RD, Shoenfeld N, Lehman A, Wolf A, Snyder L, Barzilai O (2012) Medical students' self-report of mental health conditions. Int J Med Educ. 3:1–5. https://doi.org/10.5116/ijme.4e80.28b7

    Article  PubMed Central  Google Scholar 

  26. Volpe U, Ventriglio A, Bellomo A, Kadhum M, Lewis T, Molodynski A, Sampogna G, Fiorillo A (2019) Mental health and wellbeing among Italian medical students: a descriptive study. Int Rev Psychiatry. 31(7-8):569–573. https://doi.org/10.1080/09540261.2019.1654718

    Article  PubMed  Google Scholar 

  27. Cuttilan AN, Sayampanathan AA, Ho RC-M (2016) Mental health issues amongst medical students in Asia: a systematic review [2000–2015]. Ann Translational Med 4(4):72

    Google Scholar 

  28. Noorbala AA, Yazdi SB, Yasamy M, Mohammad K (2004) Mental health survey of the adult population in Iran. Br J Psychiatry. 184(1):70–73. https://doi.org/10.1192/bjp.184.1.70

    Article  CAS  PubMed  Google Scholar 

  29. Hojat M, Glaser K, Xu G, Veloski JJ, Christian EB (1999) Gender comparisons of medical students' psychosocial profiles. Med Educ. 33(5):342–349. https://doi.org/10.1046/j.1365-2923.1999.00331.x

    Article  CAS  PubMed  Google Scholar 

  30. Bleakley A (2014) Gender Matters in Medical Education. In: Patient-Centred Medicine in Transition. Advances in Medical Education, vol 3. Springer, Cham. https://doi.org/10.1007/978-3-319-02487-5_9

  31. Dhami DB, Singh A, Shah GJ (2018) Prevalence of Depression and Use of Antidepressant in Basic Medical Sciences Students of Nepalgunj Medical College, Chisapani, Nepal. J Nepalgunj Med College 16(1):32–36. https://doi.org/10.3126/jngmc.v16i1.24224

    Article  Google Scholar 

  32. Baldwin DC, Hughes PH, Conard SE, Storr CL, Sheehan DV (1991) Substance use among senior medical students: a survey of 23 medical schools. JAMA. 265(16):2074–2078. https://doi.org/10.1001/jama.1991.03460160052028

    Article  PubMed  Google Scholar 

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Contributions

AM designed the study, BK and YB collected the data, reviewed literature, and wrote the manuscript. AM and MK analyzed the data and critically revised the manuscript. All authors approved the final version of the manuscript.

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Correspondence to Bikram Kafle.

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Kafle, B., Bagale, Y., Kadhum, M. et al. Mental health and burnout in Nepalese medical students: an observational study. Middle East Curr Psychiatry 28, 53 (2021). https://doi.org/10.1186/s43045-021-00134-4

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