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Journal of Krishna Institute of Medical Sciences University 55
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JKIMSU, Vol. 4, No. 1, Jan-Mar 2015
ORIGINAL ARTICLE
Abstract:
Keywords: Anxiety, Depression, Physical activity,
Medical students
Introduction:
Mental health disturbances, including nonclinical
depression, anxiety traits, feelings of sadness, or
Background: Mental health problems are more
commonly seen in youth, more so in medical students.
Physical activity though known to improve mental
health is difficult to follow among medical students.
Aims & Objectives: This study aimed to investigate
self-reported levels of anxiety and depression and
compare these with self-reported physical activity
among medical students in an institution of India.
Material & Methods: A Cross sectional study was done
among 430 medical students and interns of a medical
college of rural Karnataka, India. Hospital Anxiety and
Depression Scale (HADS) and International Physical
Activity Questionnaire (IPAQ) were administered to
assess mental health status and physical activity levels
respectively. Results: The prevalence of anxiety
(65.1%), depression (39.5%) and anxiety with depres-
sion (34.4%) was high among medical students. Only
18.1% of students were highly active while 35.9%
were inactive when physical activity levels were
measured. Students who were highly active and
minimally active in physical activity showed lower
levels of depression and anxiety compared to low
physical activity group. Conclusion: Mental health
problems are high and physical activity levels are low
among medical undergraduate students. Engagement
in physical activity can be an important contributory
factor in positive mental health of future doctors.
Good Mental Health Status of Medical Students: Is There A Role for Physical
Activity?
1* 2 3 3
Deepthi R , Ashakiran S , Thota Venkat Akhilesh , Mohan Reddy
1Department of Community Medicine, ESIC-MC & PGIMSR, Rajajinagar, Bangalore-560010
2
(Karnataka) India, Department of Biochemistry, Saptagiri Institute of Medical Sciences &
3
Research Centre, Bangalore-560010 (Karnataka) India, Department of Psychiatry, Sri Devaraj
Urs Medical College, Kolar-563101(Karnataka) India
temporary mood disorders are associated with
morbidity and mortality in the adolescent and
youth population [1-4]. The prevalence of mental
health disturbances among children and
adolescents remain significantly high [1-4] and
were almost similar to that of adult population [5].
The prevalence of depression among adolescents
in South East Asian region has been found to be 15
– 20% mainly due to inability to cope with intense
emotions, aggressiveness, isolation from family,
inability to keep one’s disappointments in
perspective and academic stress. Research has
consistently shown that doctors with healthy
personal lifestyle and habits are more likely to
impart healthy behaviours to their patients [6].
Physical activity is proven to improve mental
health among normal individuals and in people
suffering from mental illness [7]. The positive
association between physical activity, mental
health and treatment of mental health problems,
has been demonstrated in various studies [7, 8].
Studies have demonstrated that physical activity
has a beneficial effect on mild to moderate
depression [9, 10] and public health
recommendations for aerobic physical activity
have been found to be an effective treatment for
mild to moderate depressive disorder [11].
Research on the effect of physical activity on
anxiety has been studied in a systematic review
which showed a positive association with low
physical activity [12]. This has led to the
ISSN 2231-4261
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promotion of physical activity, within health
policy and practice, for the improvement of both
physical and mental health in the general
population.
In medical field, amount of study students must
undergo is vast and its education process is
characterized by many psychological changes
among them. This is evidenced by high prevalence
of mental disorders among medical students as
observed in various studies [13-16]. Some studies
have identified that anxiety and depression are
common problems, with students likely to suffer
mental health problems because of concerns
regarding their studies [16]. One study has
reported that 60% of undergraduate students had
elevated levels of anxiety and depression [17].
Though Medical Council of India has laid down
regulations that it is mandatory that all medical
colleges should have facilities for sports and
recreation, its utilization is doubtful. As a
consequence of the findings from this limited
amount of research among medical students in
India, this study aimed to investigate self reported
levels of anxiety and depression and compare
these with self-reported physical activity among
medical students in a medical college. Since
presence of examinations and term of study may
also have effect on mental health status, this study
also aims at assessing the association of
examinations in the next 2 months and academic
term of study of the student with anxiety,
depression and physical activity levels.
Material and Methods:
It was a cross sectional study done among medical
students and interns of a medical college of rural
Karnataka, India. Institutional ethical committee
clearance was obtained from Sri Devraj Urs
Medical College, Kolar. Study duration was one
year from May 2011 to April 2012. All 600
students were requested to participate, of which
430 students consented to participate in the study.
Questionnaire containing general information,
Hospital Anxiety and Depression Scale (HADS)
and International Physical Activity Questionnaire
(IPAQ) was administered to all the students after
taking informed written consent. Students were
asked not to write their name to maintain
confidentiality and promote getting correct
information. General information including age,
gender, are they facing exams in the next two
months was collected.
Mental state was measured using Hospital
Anxiety and Depression Scale (HADS) [18]
having a 14-item self-report questionnaire with
seven questions relating to anxiety and seven
questions relating to depression. Scoring was
based on a 4-point likert scale (0-3) with a
maximum score for each subscale being 21. For
both subscales, scores of 0–7 indicated the
absence of clinical symptoms of anxiety and
depression; scores of 8–10 indicated mild
symptoms, 11–14 moderate symptoms and 15–21
severe symptoms. The scale was originally
designed to detect elevated levels of anxiety and
depression amongst patients in non-psychiatric
hospital clinics, and therefore was thought
suitable to be use with any population who did not
have a clinically defined psychiatric disorder. This
scale was observed to have good psychometric
properties in terms of factor structure, inter-
correlation and internal consistency [19].
Physical activity was measured using International
Physical Activity Questionnaire (IPAQ). The IPAQ
[20] was an instrument designed primarily for
population surveillance of physical activity among
adults [21]. The validity and reliability of the
instrument was established in various studies [22]
Questions on time spent included physical
activities done at work, house and yard, to get from
place to place, and spare time for recreation,
exercise or sport in the last 7 days. Activities were
classified as vigorous and moderate physical
activities [20]. The total duration of physical
activity, per week, was calculated to the nearest
minute, metabolic equivalents (MET) were
Deepthi R et. al.
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calculated. Students with 5 or more days of any
combination of walking, moderate-intensity or
vigorous intensity activities achieving a minimum
of at least 600 MET-min/week were classified as
“minimally active”. Students with 7 or more days
of any combination of walking, moderate-
intensity or vigorous intensity activities achieving
a minimum of at least 3000 MET-minutes/week
were classified as “highly active” category or
health enhancing physical activity (HEPA).
Students with less than 5 days of any combination
of walking, moderate-intensity or vigorous
intensity activities or having less than 600 MET-
min/week were classified as “inactive”.
Data Analysis:
Proportions of students with various levels of
anxiety, depression and physical activity profile
were calculated. Association between mental
status and fitness was assessed using chi square
test. Odds ratios with their confidence intervals
were calculated. Pearson's correlation and co
association of anxiety and depression scores were
found out. Correlation between anxiety scores and
depression scores was done with the academic
term of study subjects.
Results:
Anxiety and Depression:
For depression, the mean score was 6.85 (S.D. =
3.8). This fell within the normal range of depressive
classification. (Table 1) The mean anxiety score for
the student cohort was 8.99 (S.D. = 4.2). This fell
within the mild symptom range. Considering the
percentage of students who fell within the different
severity band ratings of anxiety and depression,
34.9% of students were considered normal on the
anxiety subscale and 60.5% on the depression
subscale. Only 9.3% of students were considered to
have severe anxiety, with 4.2% falling into severity
range for depression. Prevalence of anxiety among
females was 70.8% as compared to males which
was 57.8% and this difference was found to be
2
statistically significant (c=9.13, df=2,p=0.005).
Prevalence of depression among males (40.1%)
and females (39.1%) were similar.
Overall combined prevalence of anxiety and
depression among students was 34.42%.
Prevalence among males (34.8%) and females
(34.2%) were observed to be similar. Co presence
of depression and anxiety among males and
females were significantly more compared to
presence of just depression or anxiety or being
2
normal (c=115.3, df=2,p=0.000) .
Males N (%)
Females N (%)
Total N (%)
Depression
Normal
112 (59.9)
148 (60.9)
260 (60.5)
Mild
44 (23.5)
62 (25.5)
106 (24.7)
Moderate
21 (11.2)
25 (10.3)
46 (10.7)
Severe
10 (5.3)
8 (3.3)
18 (4.2)
Anxiety
Normal
79 (42.2)
71 (29.2)
150 (34.9)
Mild
44 (23.5)
82 (33.7)
126 (29.3)
Moderate
42 (22.5)
72 (29.6)
114 (26.5)
Severe
22 (11.8)
18 (7.4)
40 (9.3)
Total
187 (100)
243 (100)
430 (100)
Table 1: Proportion of Anxiety and Depression among Medical Students
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Physical Activity:
Table 2 shows physical activity levels among
medical students. Considering the percentage of
students who fall within the different grades of
physical activity, 18.1% of students were highly
active, 46% were minimally active and 35.9%
were inactive. As shown in table 2 more females
were physically inactive (41.6%) compared to that
of males (28.3%) and this difference was
2
statistically significant (c=34.6, df=2,p=0.000).
Table 3 shows association of anxiety, depression
and physical activity levels between males and
females. Anxiety was 1.22 times more associated
with females than compared to males. Males were
1.8 times more physically active than compared to
females.
Association between physical activity and
mental health:
Table 4 shows that students engaging in some
physical activity were significantly less depressed
(34.1%) as compared to students who were
physically inactive (49.4%). Anxiety among
physically inactive students was 66.9%, which is
slightly higher as compared to students who were
physically active (64.1%). Students engaging in
physical activity were significantly less likely to
be suffering from both depression and anxiety
(31.2%) as compared to students who were
physically inactive (40.3%).
Table 5 shows the association of anxiety,
depression and physical activity with appearing
for exams in the next two months. Anxiety was
more commonly observed among students
appearing for exams (OR = 1.59) compared to
those who did not. Figure 1 shows the correlation
between different variables. Anxiety and
depression scores significantly decreased with
increase in the term of studies of students. As the
depression scores increased anxiety scores also
increased significantly.
Physical Activity
Males N (%)
Females N (%)
Total N (%)
Highly Active
57 (30.5)
21 (8.6)
78 (18.1)
Minimally active
77 (41.2)
121 (49.8)
198 (46.0)
Inactive
53 (28.3)
101 (41.6)
154 (35.9)
Total
187 (100)
243 (100)
430 (100)
Table 2: Physical Activity Levels among Medical Students
Mental status
Males
(N=187)
Females
(N= 243)
p
value
OR (CI)
Depression
75 (40.1)
95 (39.1)
0.83
0.97 (0.77 - 1.23)
Anxiety
108 (57.8)
172 (70.8)
0.005
1.22 (1.05 -1.42)
Depression & anxiety
65 (34.8)
83 (34.2)
0.896
0.98 (0.76 - 1.28)
Physically Active
134 (71.7)
142 (58.4)
0.005
1.8 (1.19 – 2.70)
Table 3: Association of Gender with Anxiety, Depression and
Physical Activity among Students
Deepthi R et. al.
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Mental status
Physically Active
(N=276)
Physically Inactive
(N= 154)
p
value
OR(CI)
Depression
94 (34.1)
76 (49.4)
0.002
1.89 (1.26 - 2.82)
Anxiety
177 (64.1)
103 (66.9)
0.56
1.13 (0.75 - 1.71)
Depression & anxiety
86 (31.2)
62 (40.3)
0.057
1.49 (0.99 - 2.25)
Table 4: Association of Physical Activity Levels with Anxiety and Depression
among Students
Table 5: Association of Proximity of Exams with Anxiety, Depression and
Physical Activity among Students
Variables
Exams in 2 months
(N=209)
No Exams
(N= 221)
P
value
OR (CI)
Depression
91 (43.5)
79 (35.7)
0.098
1.14 (0.98 - 1.32)
Anxiety
153 (73.2)
127 (57.5)
0.001
1.59 (1.21 - 2.08)
Depression & anxiety
80 (38.3)
68 (30.8)
0.1
1.12 (0.98 -1.29)
Physically Active
139 (62.9)
137 (65.6)
0.57
1.12 (0.76 – 1.67)
Fig 1a: Correlation between Variables Associated with Anxiety and Depression Scores.
R=0.64, p < 0.01
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Discussion:
The prevalence of anxiety (65.1%), depression
(39.5%) and anxiety with depression (34.4%) was
high among medical undergraduate students. It is
distributing to note that 9.3% of students reported
to have severe anxiety and 4.2% severe
depression. Only 18.1% of students were highly
physically active while 35.9% were inactive.
Tyson et al reported a much lower prevalence of
depression (10%) and a similar prevalence of
anxiety (60%) among medical students [23].
Previous studies which have looked at the mental
health of students have concluded that they are at
an increased risk of anxiety and depression [16,
17]. Prevalence of anxiety was more among
students appearing for exams in two months as
compared to those who did not. Though the goal of
medical education is to graduate knowledgeable,
skilful and professional physicians, somehow
medical training has some unintentional negative
effects on medical students mental and emotional
health. Studies state that student's distress
contributes to pessimism and subsequently may
affect care to patients, relationship with faculty
and finally success in their future carrier as
physician [24]. Hence the issue of potential
mental health problems in medical students is one
which needs to be proactively and continually
monitored by academic institutions.
Anxiety has been significantly observed more
commonly among females (70.2%), as compared
to males. The prevalence of depression has been
similar among males and females. The present
results are in line with previous studies, [13, 24,
25] who have reported more mental health
disorders among female medical students. This
may be due to increase in negative psychological
functioning during adolescence; females seem to
report more psychological complaints than males.
More anxiety among females can be attributed to
the fact that females have a lower threshold for
tolerating stress and also in evaluating and
Fig 1b: Correlation between Variables Associated with Term of Studies and Depression Scores.
R=-0.20, p < 0.01
Deepthi R et. al.
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JKIMSU, Vol. 4, No. 1, Jan-Mar 2015
reporting experiences as problematic. The
differences may therefore partly result from
gender differences in self-reporting styles [26].
Totally, the results highlight the need to provide
support for female medical students especially, as
they seem to be more vulnerable to psychological
problems.
Students engaged in some physical activity have
shown significantly lower levels of depression
(34.1%) than the students have been inactive
(49.4%). Students engaged with some physical
activity also have shown lower levels of anxiety
and anxiety with depression than the inactive
group. There are various studies where both
anxiety and depression were significantly
associated with low physical activity [27, 28, 29].
There has been a negative correlation between
amounts of physical activity and self-reported
anxiety and depression scores as reported by
Tyson et al [23] Hassmen et al have suggested that
greater amounts of physical activity is associated
with a reduction in depression [30]. As cause
effect relationship cannot be established in this
study, it is difficult to say that higher levels of
depression are due to a lack of physical activity. It
may be the case as suggested in other studies [31,
32] that the more depressed an individual
becomes, the less likely he is to engage in physical
activity. There are only few studies which have
explored the relationship between mental health
status and physical activity among medical
students who were not primarily identified as
having any mental health problems.
The significant increase in anxiety levels among
students appearing for exams in the next two
months has been observed than those who don't.
This study supports the findings of previous
studies; in that majority of the medical students
experience some level of anxiety during exams
[33, 34] Hashmat et al have also reported
significant lack of physical activity among exam
going students [34]. There has been a negative
correlation observed between the term of studies,
anxiety scores and depression scores. This may be
due to the behavioural adjustment made by
medical students to meet the needs of the course
over period of time. This study does not give
causal association between physical activity and
mental health as it is a cross sectional study. A
longitudinal cohort study for five years on fresh
students will help in exploring the same.
In summary prevalence of anxiety, depression and
co presence of anxiety and depression is high
among medical students. Physical activity levels
are low among medical students. Anxiety levels
are significantly higher among females compared
to males. Males are significantly more physically
active compared to females. Depression is
significantly associated with physical inactivity.
Anxiety has been significantly higher among
students who are appearing for exams in the next
two months. Anxiety and depression scores are
decreased as the term of study of students
increased.
Finally, our findings contribute to the growing
body of literature demonstrating a positive
association between low physical activity and
depression and anxiety among medical students.
Furthermore, qualitative research into the
perceptions of the role of physical activity in the
lives of students for the maintenance of good
mental health may also shed light on this
relationship.
Conclusion:
It should be of interest to the students wishing to
maintain and promote their mental health while at
medical college, and also for universities wishing
to safeguard their students emotional well-being
through the promotion of physical activity.
Fostering good mental wellbeing and preventing
mental health problems among medical students
plays a crucial role in medical education and
health improvement.
Deepthi R et. al.
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Acknowledgements:
We thank all students of SDUMC, Kolar for their humble and enthusiastic participation in the
research.
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*Author for Correspondence: th nd
Dr. Deepthi R, No – 620 G, 'Raghava' 35 Cross, Rajajinagar 2 Block, Bangalore,
Karnataka, India -560010. Cell: 0919731885405 Email: drdeepthikiran@gmail.com
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